Chains of Love.

Tags

#justiceforallthedudes, #justiceforLB, Connor Sparrowhawk, learning disability, Local Authorities, NHS

More satisfactory news for #JusticeforLB recently.  The Slade House site, which Southern Health had been intending to retain in its property portfolio, with a view to selling it off and keeping the profit, is being returned, lock, stock and barrel, to Oxford Health. Thank the entity – or epithet – of your choice for that.

Keeping Slade House for Oxford wasn’t part of the original Connor Manifesto, but as Southern decided – or were pushed – to cut and run from providing services in Oxfordshire, the fate of the site grew in importance.  Sloven, although demitting from healthcare in Oxfordshire, still intended to hold on to all the Oxonian physical assets that had transferred to them at the start of the contract.  But this time, it wasn’t only #JusticeforLB howling, “You have got to be kidding me!”  Oxfordshire residents and local politicians were equally outraged. Under no circumstances could it be morally or ethically acceptable that Sloven would get away with (1) taking over a faltering service, (2) running it down further until it killed a patient, (3) using that failure as a pretext for ceasing to provide services, but (4) still keeping hold of the assets needed for alternative service provision.  Yet the drafting of the contract with Sloven had been so sloppy that, in strict legal terms, Sloven’s retention of the real estate was a distinctly plausible outcome. The Justice Shed began contingency planning for protests, should it ever look like happening.

Under pressure from patients, from local residents, from the press and from politicians, Southern Health eventually conceded that, in the circumstances, insistence on pocketing all the windfall gains from a patient’s death wasn’t tenable.  Nevertheless, the wholesale return of the Slade House site was still by no means a certainty.  As recently as April, Southern were still haggling to put conditions on the return of the site, so that they could take a cut of any profitability, were the site to be decommissioned subsequently.  Continued intervention, not least from outgoing MP Andrew Smith, finally got the matter resolved in Oxford’s favour.

‘Just glad I don’t have to chain myself to the fence‘, wrote Connor’s mother.

I know she would not have been alone there.  Whether #JusticeforLBers would have been able to encircle the whole site, Greenham-Common-Style, I’m not sure, (while smaller than the Common, it’s still a fair old skelp of ground) but I know we’d have had a good crack at it.  In any case, it seems there were enough people who cared sufficiently about LB, to form a virtual chain around the site and protect it.  A chain of love, if you like.

The question now, of course, is what should be done with it from here on?  On Horspath Driftway, at the southern end of the Slade House site, there is – or was when the Google  Earth images were taken – a sign saying ‘Oxford Health and Wellbeing Centre’.  If only, eh?  But it might be a good place to start.  The Connor Manifesto says that for all dudes – Oxford-based or not – there should be:

• An effective demonstration by the NHS to making provision for learning disabled people a complete and integral part of the health and care services provided, rather than add-on, ad hoc and (easily ignored) specialist provision
• Proper informed debate about the status of learning disabled adults as full citizens in the UK, involving and led by learning disabled people and their families, and what this means in terms of service provision in the widest sense and the visibility of this group as part of ‘mainstream’ society.

Back when LB was in the Unit, the struggles, headaches and sheer bloody terror of ‘transition to adult services’ was something I understood only with my head; not, as now, with my churning gut.  G was pre-adolescent, still very definitely a child, rather than a ‘young person’; the transition of the time was the move from primary to secondary school.  But as Pagnol says, “Le temps passe, et il fait tourner la roue de la vie comme l’eau celle des moulins”*.  It’s not just E who has grown and changed: G is at the threshold of ‘transition’ and we have been introduced to a new actor in the production of ‘The Life of G’: the 14-25 Officer.

I have to say, I do not know what this person is for.  Allegedly, he is there to smooth G’s path through ‘Preparing for Key Transitions’ and ‘Preparing for Adulthood’, but so far has contributed nothing: merely collated the documentation of a few things that were already being done elsewhere (and better) by other people.  I’ve asked, repeatedly, for an outline of post-16 options, and been told it’s up to me to scope all that stuff out.  So what’s the point of this officer?  He seems neither use nor ornament.

Equally, I am having trouble with the NHS.  I’m told that as G is not in a special school, paediatric services will cease at age 16.  Never mind that the blasted EHCP – including the H-for-Health component – runs on to 19 or even 25.  Never mind that said EHCP is novella-length, or that G sees so many different health professionals that we need a lever arch file with about two dozen dividers in it to keep track of all the appointments.  Never mind that the twice-yearly consultations with the developmental paediatrician are the only place where I can feel that here is another person, besides myself, who has an overall – if not finely detailed – view of all G’s health needs and direct lines into the secondary-sector specialists that G needs.  Nope.  Immediately G reaches blow-out-16-candles day, all this will fall to the GP (lovely person, but 10-minute appointments can’t substitute for the hour and a half or so that the paediatric reviews get) and the Learning Disability Community Nursing team.

That’s another thing.  Learning Disability ‘medicine’ is embedded firmly in mental health services.  You can’t get a consultant in Learning Disability as such, only a psychiatrist.  Children’s learning disability services are part of CAMHS and they don’t seem to deal with learning disability unless the child also has autism and/or behavioural problems.

And there’s the rub.  G isn’t autistic and doesn’t – at present, at any rate – have any mental health problems.  G is learning-disabled.  G has normal teenage anxieties about fitting in and being part of the group and what-will-I-be-when-I’m-grown-up.  Any additional difficulties with that are not due to mental illness, but to developmental delay that means G isn’t as proficient as the typical teenager at processing those anxieties (and goodness knows, it’s not easy even for the most ordinary and laid-back teenager).  All G needs to stay on top of things is extra time: more time to think about stuff, more time to get responses out, a bit longer to ease into being an adult.

It’s always been the same.  I can remember various, ahem, discussions with various professionals during G’s infancy, during which I was criticised for, allegedly, seeking my own gratification by keeping G over-dependent on me.  Not pushing hard enough for whatever the flavour-of-the-month goal was: weaning; walking independently; having support withdrawn at nursery; and similar things that G wasn’t yet ready for.
My conversation-stopper was, “You do know that G’s genetic condition causes developmental delay, don’t you?  What do you think that means in real life?”
“Erm, well, G’s development is, um, delayed?”
“Obviously.  AND?”
“Er, not quite sure what you are getting at….”
“It means <pause while I mentally insert, ‘you nincompoop’>, G needs to be a baby for a bit longer.”
And of course, when G was good and ready, all those things happened: but on G’s schedule, not anyone else’s.   I just wish there were somebody now willing to work with, rather than on, G.

I hear that since Cheshire West got a pasting in their DoLS case over P, an adult with Trisomy 21, the West Cheshire health bods have appointed a specialist health facilitator for learning disability.  This person will tap into mental health services if they are truly needed, but is primarily concerned with the overall health care of learning-disabled young people and adults: building a person-specific system, based on the presumption-of-capacity provisions of the Mental Capacity Act, to ensure that during ‘transition’, each learning-disabled person’s health-care and communication support needs are fully documented; that they are plugged in to appropriate health support systems; and that if they have to go into hospital at any time, full and accurate information goes with them, to prevent them being put at risk by ignorance.  If only there had been something of the sort for LB, so that the staff would have had his epilepsy, and What Not To Do, set out for them in unmistakable terms.

Apparently, the West Cheshire person holds the only such rôle in the country, so I presume that elsewhere, dudes with physical health problems are potentially still as much at risk as LB was.  But maybe the Slade House site could be repurposed – whether by reuse or by sale –  to provide a permanent Connor Sparrowhawk Learning Disability Health Facilitation Service in Oxfordshire.  And maybe it could, by example, spread learning disability good practice to every Health Trust.

I don’t know if Connor’s family would see that as a worthwhile memorial to their Laughing Boy.  I just have a picture in my head of the love that they have for him, forming the first link in a chain that would wind on endlessly, through other loving families and dudes, into the future.

 

LB: Another Day…In Court.

Tags

#justiceforLB, Connor Sparrowhawk, preventable deaths, Sloven Health

It was confirmed yesterday that the Health and Safety Executive are going to prosecute Southern Health for the failings that led to Connor’s death.  To paraphrase Norman Lamb: Good, and about bloody time.

Still can’t get my head round why the Crown Prosecution Service did not pursue a corporate manslaughter charge: the inquest jury found that serious management failures at Slade House contributed to Connor’s death, so presumably the resulting breach of Southern’s duty of care towards him was deemed insufficiently ‘gross’.  Call me naïve or thick but I can’t see how much grosser it can get, than having systems which allow a clinically vulnerable person, carelessly, in defiance of known diagnoses and of recent events confirming clinical risk, to be put into a situation with a high potentiality of death.  Especially given that the risk, and the death, actually eventuated.

However, the Health and Safety Executive seems to have a good track record of holding companies, and their directors and senior managers, to account.  More slog for LB’s family, seeing this one through, on top of the wildly inappropriate General Medical Council (GMC) and Nursing and Midwifery Council (NMC) approaches to involving families in disciplinary proceedings.

I watched the news coverage of the announcement.  But as Huw Edwards launched into the introduction:  “…Connor Sparrowhawk, who was eighteen….” and the familiar images of LB as a giggling toddler and an ice-cream-eating teenager played over, I had an almost physical sensation of a bit of my mind slipping sideways.

Eighteen.  That can’t be right.  LB is three years older than E; he was in Year 13 when E was still in Year 10.  LB was a young man and E was still a baby-faced, coltish boy, lanky and spindly, with what appeared to be more than the standard complement of knees, elbows and shoulder-blades; still in school uniform, still to sit GCSEs, still to graduate into a ‘business dress’ chain-store suit and Sixth Form, still to choose and sit his A-Levels, still to make decisions about where to go next.

Now, E is an undergraduate. At nearly 20, with a full set of whiskers and (following a recent student-prank-gone-wrong) a No. 1 crop, he looks nearer 30.  He’s playing sports three times a week and hitting the gym in between, and even if his sixth-form suit hadn’t developed peculiar pinkish patches after repeated dry-cleanings, he still wouldn’t be able to wear it, as his chest and shoulders have packed on an extra six inches of muscle since he left school.  He’s revelling in having left behind the write-a-mark-a-minute constraints of A-levels, in being able to pursue his academic interests and do the research needed to back up his hypotheses, in finding a circle of like-minded mates for study and leisure, in being responsible for his own schedules, meals, laundry, and employment for spending-money.  So if E is this mature young man, Connor, surely, is approaching his mid-twenties?

Of course, he isn’t.  And it hits me all over again.  While LB has been an ongoing presence in so many lives, and while I have continued to think of him as older than, and therefore somehow growing up ahead of, my own son, Connor has in fact stopped.  Stayed as he was on that brilliantly sunshiny morning, forever an eighteen-year-old schoolboy, about to visit the Oxford bus company.

It’s not that I don’t know.  It’s just that the enormity and awfulness of the realisation seems new and raw, every time.  And as I remember to gasp in another breath, and blink away the prickle of tears, the screen is filled with an image of Connor’s mother, talking to the BBC’s Michael Buchanan.

“He should never have died.  And I… just miss him so….He’s left an unimaginable hole in our lives.”

*****

Appallingly, Connor is not the only one remaining in the same place.  Southern Health is still, still, overclaiming (otherwise known as outright lying) about its actions. “Tonight,” said Huw, “the Trust has apologised again to his family”.  However, and to whichever bit, of Connor’s family the Trust apologised, it didn’t include doing so, in words, to Connor’s mother.

Earlier @Southern_NHSFT told BBC News they have apologised again to us. Odd. Not heard a dicky bird. #JusticeforLB

— Sara (@sarasiobhan) May 9, 2017

If Sloven can’t get that right, after nearly four years, they can’t be trusted on any of the alleged improvements they’ve made, either.

Oh dear. @Southern_NHS, apologising to us unreservedly through a statement to the media ain't an apology. Seriously. #JusticeforLB

— Sara (@sarasiobhan) May 10, 2017

No learning. No honesty. No Trust.

Dear @Southern_NHSFT, can you please stop telling journalists you have apologised again to us. You haven't. Thank you. #JusticeforLB

— Sara (@sarasiobhan) May 10, 2017

See you in Court, Sloven.

 

Some Justice for LB.

Tags

#justiceforLB, Connor Sparrowhawk, preventable deaths

After a day’s intensive pre-trial mediation, Southern Health have finally, finally, formally acknowledged what they should have admitted from the start: that the Trust, its processes, procedures and policies in respect of staffing, training, communication, clinical history taking and safe provision were negligent; and that as a result, they caused Connor Sparrowhawk’s death, in breach of his Article 2 human right to life.  At last, no more ‘not us, guv’.  No more ‘alleged’.  It just won’t (white)wash any more.  The Trust further admits to breaching the Article 2 rights of Connor’s family, by the Trust failure to facilitate the required ‘effective and proper investigation’ into Connor’s death.

Connor’s family has been awarded a sum of money, a substantial sum that is nevertheless a fraction of the legal costs which the Trust splurged on mounting an offensive defence at Connor’s inquest; a sum which is probably just sufficient to cover his family’s own legal costs.

In the last paragraph, the Trust acknowledges that Connor’s mother, Dr. Sara Ryan has ‘conducted herself and the Justice for LB campaign in a dignified, fair and reasonable way’, and explicitly disowns any statements from its staff or their families to the contrary.

Not before time, there is a new dish of the day on the Sloven menu.

What I want to know is, why wasn’t this statement (minus the financial settlement that would have had to be negotiated subsequently), the statement that was put out immediately after the end of Connor’s inquest on 16 October 2016?  Come to that, why wasn’t it the statement that was put out after the Verita report in February 2014?  Why has it taken nearly eight months to get from jury verdict to formal Southern Health admission, and then only under threat of a further, Human Rights-based, court case?

It seems reasonable to speculate that the change of mind and direction may have something to do with the change of Chairman, so maybe things Southern are, at last, moving in an unSlovenly direction.  However, although as part of the settlement, Southern Health has agreed to put the statement on its website for four weeks, it has done so in the sketchiest, most grudging form.  With (heavy sigh) yet more bloody-minded spin:

We have now been able to come to a successfully mediated settlement with Connor’s family, as detailed in the statement attached on the right hand side of this page.

‘successfully mediated’, forsooth, as though Sloven had been actively seeking a just settlement, against the resistance of Connor’s family!  Some <expletive deleted> success!  Can’t fault them for consistency: they never fail to disappoint.

Given that so many of the Trust’s previous specious-spin statements have remained on the website for years, it will be interesting to see if this one stays there past the 28-day period, and if so, for how long.

Whatever Southern chooses to do, I promise that the statement will remain available on this site for as long as the blog exists. As, I am sure, it will remain on the Justice for LB site and many others.

This is not, even yet, Justice for LB.  Beyond admissions, there is accountability.  Whether that involves proceedings for corporate manslaughter, for Health and Safety breaches, or under the Fit and Proper Persons Requirements, I and the other Justice for LB supporters continue to uphold Connor’s family to travel just as far down those routes as they want to go.

 *****

Full Statement in PDF format here: 08 06 16 – CS – Mediated Statement

*****

I.Can’t.Even.

Tags

#justiceforLB, (un)accountability, Connor Sparrowhawk, institutions, learning disability, NHS, preventable deaths, Sloven Health

This latest #JusticeforLB development is almost beyond comment.  It does, however, throw into sharp relief the siege mentality obviously operating within Southern Health; and speaks volumes about Sloven culture and the messages purposefully circulated within, and outwith, the organisation.

The transcript below comes from a message left on LB’s mother’s office answerphone from someone claiming to work for Sloven.  It doesn’t much matter whether the caller is a member of management, a lower-ranking staff-member, or just an unconnected crank; she has obviously absorbed and internalised an execrable attitude to LB and to his mother, and feels justified in spewing it out.  A toxic attitude that aligns precisely with Sloven’s dealings with LB and his family, all through the more-than-three-years since LB was admitted to STATT.

And Sloven’s response?  Of a piece with their previous form, and with the call.

Sloven are not setting up an enquiry, actively seeking the culprit and requiring staff to disclose information.  They’re not even setting up an internal enquiry and asking for all available information.  Oh no.  They will, apparently, set up a ‘full internal investigation’, if and when they receive ‘any information’ in response to their ‘urging’.

Pathetic.  As always.

 – – – – –

Good morning, hello. Hi, I believe this is a message for Dr. Sara Ryan, um, I’ve been seeing on the media about your son, your poor son that died under the care of Southern Health.  I work for Southern Health and I’m, it, it’s awful that you’ve lost him, I’m so sorry that you have done, um, ’s tragic, and … I hope you find some closure after the report, the, um, issue of the GMB … CQC report today, but I do think you are being reall- very vindictive.  I think you are a vindictive cow.  On TV all the time, ummm, slating the NHS Southern Health.  With your intelligence background, you know, as much as anybody else knows, that Southern Health only took over those units in Oxfordshire recentl-, you know, the recent months before your son died.  You know, with your background, it takes a while to make changes in anywhere, and I think now you’ve just become a bitch and you want some attention, but you are vindictive, you are unpleasant, and you are a nasty cow.

This message was recorded at 9.33am on Friday April 29th.  To save this message press 1.  <beep> To-  Message saved.

– – – – –

Positive Outcomes.

Tags

#justiceforLB, Connor Sparrowhawk, inquest, LB Bill, Local Authorities, NHS, preventable deaths, Sloven Health

Friday afternoon.  The verdict finally came in at LB’s inquest.  In an ‘you don’t need a weatherman’ kind of way, the jury’s questions to witnesses had suggested they were finding the family’s perspective on events more convincing than the Trust ones.  Still, the extent of what the jury eventually found was more than I, for one, had dared hope for.

They didn’t buy the ‘died elsewhere’ finagle, stating firmly that Connor died in STATT, not at the John Radcliffe Hospital.  They said that his death was ‘contributed to by neglect’ and set out a laundry list of serious failings, both within the unit, and beyond it.

It was exactly the right verdict, and the only shame was that it had taken so long to arrive: 824 days, to be exact.  I watched the BBC news segment and hoped Connor’s family weren’t feeling too poleaxed by the media interest.

After Dad’s inquest finished, I remember being a peculiar mental place where most of my thoughts seemed suspended, but also twin-tracked.  My body, voice and volition still seemed to be operating effectively, and one track of my consciousness was observing and noting this with rather surprised approval.  The other track seemed to be running through an empty cavern of what just happened? so vast that all I could hear were echoes of thoughts that petered out into nothingness.

I remember handing out the family statement to the journalists and saying brief goodbyes to my mother and siblings; and then, of all the bizarre things, rushing to a shop to pick up a Dalek costume for Eldest, who was off to a Dr. Who convention the next day.  I know I had just enough time to skedaddle to the station and make it across the platform and into the train, about 5 seconds before the doors slid closed.  After that, it is pretty much blank.  Thinking back to it now, I have a sensation of vacuum in my head, as though all my thoughts had been sucked out into that whispering void.  If you’d asked me a question, I could probably have given you a pretty logical-sounding Track One answer.  But the real me was lost, somewhere down along Track 2.   Fortunately for me, I didn’t have to answer journalists’ questions.  They were content with the pieces of paper.

Connor’s family, on the other hand, walked out of court into a battery of cameras: BBC; ITV; Channel 4; journalists asking for reactions to the Sloven ‘apology’ (which the Slove PR department extruded within minutes of the verdict being delivered; it went to the media, not to Connor’s family).  On this Friday evening, I felt that familiar blankness of relief and released mental tension; I imagined Dr. Ryan might well also be beyond ordered thought or identifiable feelings.  Late the following morning, she tweeted, ‘Still no coherent inquest thoughts’.

I watched the television segments about the inquest.  Channel 4 and ITV pitched it pretty near perfectly, although I was still shouting into the ether when Sloven’s Medical Director said she was sorry for ‘what happened to Connor’ (“NO! You should be ‘sorry for what WE DID to Connor and for how WE FAILED him by not providing proper care’, you wretched woman!”) and when she began huffing and eye-rolling, even as she strained to avoid being verbally critical of Connor’s mother, I nearly sent the remote through the screen.

But Friday’s 10pm BBC report by Michael Buchanan bothered me.  For me, it was jarring almost from the outset, starting by saying that Connor ‘died tragically’.  I was disappointed to hear a BBC reporter using a rhetorical flourish that could have been lifted straight from the Sloven Manual of Duplicitous PR.  Justice for LB has been calling out the ‘tragedy’ trope for eighteen months; and still is.  Regrettably, I found the ending of the piece even worse: after alluding to Justice for LB and the LB Bill, it finished by saying that Connor ‘would not have died in vain if the NHS learns lessons from his preventable, untimely death’.

That had me squawking at parrot pitch again.  As did the question on BBC Breakfast on Sunday about ‘what positive things have come out of your (Dr. Ryan’s) experience?’; the questioner was clearly angling for a triumph-from-tragedy story.

Listen up, and listen well, folks, because here is where I lay it on the line for you.

There ARE no upsides to losing a child.  The unnecessary death of a young man is not something that has positive aspects, spin it how you like.  Connor’s death WAS in vain.  His death was pointless and neglectful and preventable and appalling and couldn’t-care-less and just plain wrong in every respect.  Nothing, nothing, can redeem that.

He was sacrificed, not to some greater good (as if any good, however great, could merit such a sacrifice) but to organisational cheeseparing and the vanity of clinical and managerial staff.  In their egotism, certain of them refused, and still refuse, to acknowledge, or even admit the possibility, that they were in error of any kind.  Some, like the psychiatrist Valerie Murphy, mulishly insist that they made correct decisions at all times.  Others, like the Chief Executive Katrina Percy and Medical Director Lesley Stevens, make media-friendly, reputation-gilding, unforgivably tardy non-apologies or half-apologies; all of insulting inauthenticity.

But even if these monstrous egos could be deflated and brought to genuine remorse; even if every Health Trust and Local Authority in the country learned the lessons of LB’s death and put them faithfully and carefully into immediate practice; even if LB Bill were to be passed tomorrow and fully implemented the day after – Connor’s death would STILL be in vain.

Simply, it shouldn’t take the unnecessary death of a young man to prod organisations and people into doing the right thing.   It shouldn’t need that, and it certainly isn’t worth it.  Connor should still be here, living a good life the way he wanted to, and they should be doing the right thing anyway.

 

LB’s Inquest: Day 10, Afternoon. The Verdict.

Tags

#107days, #justiceforLB, Connor Sparrowhawk, inquest

For Connor
For Sara and family
For all the dudes

Thanks to George Julian,
to all the #JusticeforLB team
to the Coronial service, to INQUEST.org.uk
and to the jury for their thorough, comprehensive and caring scrutiny.

***

13.36  The jury have returned to Court, but @Southern_NHSFT counsel are not here!  #JusticeforLB.  Coroner returns, everyone is here, the jury foreman stands.  The jury have reached a unanimous finding.

Name of deceased confirmed as Connor Sparrowhawk.

Connor died on 4 July 2013 at @Southern_NHSFT STATT.  No cardiac activity was detected with death pronounced at John Radcliffe Hospital.

Connor died as a result of drowning following a seizure in the bath, contributed to by neglect #JusticeforLB.

Lack of clinical leadership and lack of training and supervision; failure to conduct a history and conduct a risk assessment.  Inadequate communication with Connor’s family and between staff in relation to LB’s epilepsy needs and risks #JusticeforLB.

Was there a failure in the systems in place?  Yes, in training and guidance.  Too few staff were trained in epilepsy on the unit; training was too limited and insufficient on the unit.  Guidance was considered inadequate, the epilepsy toolkit was not provided to staff on STATT despite being available @Southern_NHSFT.  Lack of clinical leadership on the STATT unit @Southern_NHSFT.

Errors of omission to Connor’s care once admitted to STATT: bathing arrangements, full history shd been taken and informed a risk assessment.  Lack of communication with Connor’s family and missed opportunities to conduct a risk assessment.  Lack of communication with Connor’s family while he was on the unit.  Clinical team failed to identify a lack of epilepsy risk assessment plan @LBInquest #JusticeforLB.

Jury now asked to each sign the record of inquest @LBinquest #JusticeforLB.

Coroner: Only 1-2% of inquests have juries and thanks the jury for their service.

Coroner will make a report under Regulation 28 on the prevention of future deaths #JusticeforLB.  Prevention of Future Death report to @Southern_NHSFT will cover two areas:

First issue involves observations @Southern_NHSFT; significant confusion amongst staff.  Coroner will focus particularly on inpatient obs re bathing and epilepsy, doesn’t share @Southern_NHSFT confidence around sight/sounds obs.  Clear guidelines from @Southern_NHSFT are required and clarity around what is meant in practice in relation to observations.  We’ve heard @CareQualityComm are not keen on full ban of bathing and Coroner does not recommend.  Will copy report to CQC for their comments.

2nd focus is RiO and epilepsy risk and training; there’s no designated place for relevant risk details.  We’ve heard toolkit is very good but need information to be accessible.  Focus also required on staff to be trained in how to use RiO and where to put relevant information.

STATT is closed.  Coroner is encouraged that there’s a process of signing off and validating CTMs now.  Coroner understands there have been changes to observation sheets.  Coroner: We’ve heard there is formal training at the Trust around communicating with families.

Coroner will continue to make enquiries into 2006 death of patient on STATT, may yet re-open that inquest; bears looking at in this context.  Coroner considers late disclosure concerning and will be writing to @Southern_NHSFT to seek an explanation; shd have been shared months ago.

Coroner offers his condolences to Connor’s family, friends and supporters.

Thanks offered by @paulebowen to members of the jury and the Coroner and Coroner’s officer @LBInquest.

14.00 The inquest is closed.

***

http://justiceforlb.org/inquest-verdict-connors-death-was-contributed-to-by-neglect/

http://www.bbc.co.uk/news/uk-england-oxfordshire-34548638

LB’s Inquest, Day 10: Jury Deliberations and Prevention of Future Deaths

Tags

#107days, #justiceforallthedudes, #justiceforLB, Connor Sparrowhawk, inquest

***

10.47  Jury @LBinquest return for day, reminded of their instructions and sent out to continue deliberations #JusticeforLB.

Coroner is discussing the Prevention of Future Deaths report that he has the opportunity to write. More info here https://www.judiciary.gov.uk/related-offices-and-bodies/office-chief-coroner/pfd-reports/ …

Submissions now and later this morning the Coroner will announce whether he intends to produce a report #JusticeforLB.

10.48  We consider the immediate Prevention of Future Deaths issues as following, @paulebowen [Counsel for LB’s family] outlines…..

1) Communication with families/carers and issues of consent and autonomy;

2) Training and guidance for staff on balance of dignity and safety;

3) Communication between staff inc problems with RiO and recording info; change in practice as result of transitioning to computer system. Previously responsible clinicians would sign off paper care plans and risk assessments; disconnect now and lack doctors supervising plans;

4) Training: how effective can training be if staff can come to @LBinquest and still maintain its ok to leave LB in bath for 15 mins?  There is a gap between what the Medical Director @StevensLesley at @Southern_NHSFT is saying shd be done and what is happening on the ground Given @Southern_NHSFT‘s high reliance on agency staff and poor staff retention how do they ensure agency staff are adequately trained?

5) Handover periods – disconnect between staff thinking not enough time and management thinking there is and patients get lost in middle

6) Clinical Team Mtgs – named nurses only went CTM on one occasion, how can have patient centred care if ppl who know patient aren’t there?

7) Holistic care – clarity required around observations/checks and psychiatric/holistic obs; obs policy doesn’t require holistic approach

Concerns around @Southern_NHSFT ability to learn lessons outlined by @paulebowen

Consistent failure to disclose info in timely manner.  Documents served to the family days before inquest, found out during inquest about previous death on STATT @Southern_NHSFT #JusticeforLB

10.58  PB [to Coroner]: Very grave concerns that not all information that’s relevant has been disclosed to your inquest by @Southern_NHSFT #JusticeforLB.  We know that we and the Coroner have not seen the SIRI report from 2006; must be relevant to prevention of future deaths #JusticeforLB.  An enquiry into an Article 2 inquest must be thorough, you have not seen all the information because the 2006 report has not been found.  PFD reports are intended to influence practice…. it falls in yr jurisdiction to make it clear that @Southern_NHSFT failed to disclose.

11.07  Now @StevensLesley of @Southern_NHSFT gives evidence. We won’t be tweeting it.

LB’s Inquest: Day 9, Jury Deliberations.

Tags

#107days, #justiceforLB, Connor Sparrowhawk, inquest

For the lovely @sarasiobhan, Rich, family and friends,
who are demonstrating a warmth & capacity for joy
in circumstances beyond grim,

and for George Julian,
who has discovered depths of exhaustion she never imagined, but is still live-tweeting, on the @LBInquest timeline, the information you can read below.

***

16.54  Jury returns; one note has been passed to the Coroner about an inconsistency in the paperwork with regard to place of death.

16.55  Coroner: It’s a matter for the jury, this does crop up occasionally, have paramedic evidence no cardiac output when he arrived at STATT.  Dr Hormbrey pronounced Connor Sparrowhawk dead at the John Radcliffe at 10:18.

16.56  Coroner advises jury on how they may address it.  Jury are sent away for the day until tomorrow; given warnings not to discuss the case.

16.57  We will next tweet here when the jury return with their determination at some stage tomorrow (hopefully).

LB’s Inquest: Day 9, Afternoon.

Tags

#107days, #justiceforLB, Connor Sparrowhawk, inquest

For the lovely @sarasiobhan, Rich, family and friends,
who are demonstrating a warmth & capacity for joy
in circumstances beyond grim,

and for George Julian,
who has discovered depths of exhaustion she never imagined, but is still live-tweeting, on the @LBInquest timeline, the information you can read below.

***

14.12  Jury returns and Coroner apologises to them for the delay due to legal and procedural issues this morning.  Coroner will give jury @LBInquest directions of law and will sum up evidence that they have heard.

14.21  Coroner directs the jury that their findings must be based solely on evidence heard in court.

14.22  You have heard all the evidence in this case. The evidence includes the evidence of witnesses from the witness box…statements of witnesses that were read, and other documentary evidence.

14.23  Jury has to answer four questions: who was the deceased and where, when and how did Connor come to his death.  You are required to enter the immediate cause of death 1a with underlying condition under 1b.  In answering the questions you may use judgmental words such as ‘inadequate’, ‘improper’ or ‘insufficient’, and terms such as ‘defect’, ‘failure’, ‘serious failure’, ‘very serious failure’ or ‘gross failure’, but you must avoid using words…Sorry, failed tweet, can use above but not ‘negligently’, ‘carelessly’, ‘recklessly’ or ‘in breach of their duty of care’.

14.26  It is not in dispute, you may record as follows: “Connor Sparrowhawk died by drowning following an epileptic seizure while in the bath”.  You may add words ‘contributed to by neglect’ if you are satisfied, on the balance of probabilities, that there was a very serious failure

14.27  In addition you are asked to provide a short narrative setting out contributory factors to Connor’s death.  Jury will be asked to answer a series of questions:

Qu 1 Was there a failure in the systems in place?

Q2 Was there any error or omission in Connor’s care at any time after his admission to the STATT on 19 March 2013?

14.29  Considerations for Qu1 – whether staff received adequate training in assessment, care and risk management of epilepsy in patients like LB.  Whether staff were provided adequate guidance in assessment, care and risk management of epilepsy in patients w learning disability like LB.

14.31  Considerations Qu2: focus on proper observations, obtaining adequate history, risk assessment, communication with LB’s family…communication between staff at STATT and failures in record keeping.

14.32  Coroner will now sum up the evidence that has gone before the jury; warnings are made about hearsay and disputed evidence.

14.33 Who Connor was is not in dispute; was a pathology report [requested by the jury and provided].

14.34  Was a statement from Lenka Mullerova who couldn’t be located to come to the inquest and be cross-examined; Coroner re-reads her statement.

14.36  Coroner re-reads paramedic Daniel Chilvers’ statement to the jury.

14.38  Coroner now re-reads the statement of Phil Hormbrey, the Emergency Department Consultant.

14.39  Coroner re-reads some of Joanna Ciapala’s statement, she’s a psychologist who facilitated the ‘Let’s talk about feelings’ group on STATT.

14.46  Coroner reads through sections from statements of witnesses who gave evidence in person.

14.49  We’re having twitter problems, Coroner is recapping what we’ve already heard so we won’t tweet more of summing up.

14.57  Twitter failure earlier, this is instruction given to the jury about what sorts of words they can use in Section 4.

15.40  Coroner finishes recalling the evidence that has been shared; written directions will be given to the jury shortly, alongside jury bundle.

15.41  Coroner: It’s important you consider the documents alongside the oral evidence you’ve heard.  Also take into account these events were two years ago and memories can fade.

15.41  Jury warned not to look things up on the internet.

15.42  Coroner asks the jury to attempt to make a unanimous decision, if not they’ll return to court for more direction.  Jury asked to appoint a foreperson or chairperson, no additional responsibility but will be spokesperson in court.  Jury told to take as much time as they need; may return today but no need. Deliberate until 5 pm today and return tomorrow if needed.

15.45  Jury leave court; we’ll tweet any further legal discussions on @JusticeforLB and return here with a determination when available.

LB’s Inquest, Day 9: Legal Submissions.

Tags

#107days, #justiceforLB, Connor Sparrowhawk, inquest

15 October 2015.  This morning was entirely taken up with legal submissions regarding the Coroner’s summing-up and directions to the jury.  The submissions and decisions will be posted here after the end of the case.

16 October – @JusticeforLB tweets from yesterday now shown below.

Legal submissions and discussions before jury returns for @LBInquest today. It will cover what can be put before them. We’ll tweet here {@JusticeforLB}.

Coroner explains he’s spent time looking at the proposals shared re what will go to the jury and the instructions @LBInquest.  Coroner: directions to jury and conclusions; @paulebowen provided directions from law and jury, Mr Walsh minor edits and Ms Paterson submissions.

Fiona Paterson for @Southern_NHSFT: have put submission in about training and guidance.  Coroner rules training *is* a central issue and it should go before the jury in @LBInquest.  On the evidence training is very much a central issue and something the jury need to deal with @LBInquest.

FP checks with Coroner that he’s ruled on everything in the jury bundle, 4 items to be ruled on.  Discussion re whether Health Action Plan should be in the jury bundle; @Southern_NHSFT wish for it to be included.  Mr Dullaghan’s evidence was the risk assessment box was ticked incorrectly @LBInquest.   To be made clear to jury.  All notes of all CTMs (clinical team meetings) will be included in the jury bundle @LBInquest.

Coroner: before we turn to detail of submissions can we deal with practical issue about where things go on record of @LBInquest.  Coroner suggests that the mechanism of death should go under how in Box 3 and wider narrative in Box 4 @LBInquest.  Now @paulebowen suggests Connor Sparrowhawk died of drowning following a seizure in the bath but ‘neglect rider’ should also go in 3.  Coroner doesn’t agree to @paulebowen suggestion but instead agrees Box 3 should say ‘See Box 4’ if jury wish to mention neglect.

Now @paulebowen suggests can shortcut some of deliberations by directing jury when there is agreement by all parties.  PB: Only question jury has to answer, whether they’ll add a rider ‘contributed to by neglect’ and whether to add narrative.  Coroner taken to existing law by @paulebowen to demonstrate how you can have short form descriptive verdict with a neglect rider.  Coroner suggests neglect should be in narrative, @paulebowen addresses him on the law #JusticeforLB.  We’re all agreed at the bar you should.  PB: The finding of how LB died is not in dispute so the jury can make that finding, then they can add neglect rider if wish #JusticeforLB.

PB to Coroner: What if anything will you say in qualification to the word gross; how will you qualify basic care and attention?  PB has proposed ‘basic care’ as term to be used #JusticeforLB.  PB proposes test for neglect: it amounts to a failure which caused or contributed to LB’s death more than trivially, negligibly or minimally.  FP for @Southern_NHSFT suggests dictionary definition for gross ‘total and complete, or flagrant and extreme’.  PB wants legal definition.  PB takes Coroner to Jervis @paulebowen thinks shd direct the jury that a serious failing is sufficient to amount to a gross failing.  Previously @paulebowen agreed that very serious failing would amount to a gross failing, but bar is not agreed so now feels shd be serious.  Now @paulebowen reads from case law about the definition of gross and the matter of degree of failure required to be gross.  Coroner proposes we use ‘very serious’ as that’s how we’d listed the evidence and to do otherwise wld be more confusing.

Now discussion of whether jury can focus on a series of individual failings or can they aggregate failings #JusticeforLB.  FP @Southern_NHSFT suggests failings should not be allowed to be aggregated; @paulebowen suggests case law allows aggregation #JusticeforLB.  Three examples of case law to support aggregation of neglect offered by @paulebowen.  Coroner considers @paulebowen is right about this issue but will allow Fiona Paterson for @Southern_NHSFT to come back on it in a moment.

Now discussion of case law around whether failure to conduct basic checks is failure of basic medical attention.  ‘The jury are precluded to make any findings that suggest attribution of civil liability’ so shd avoid negligence questions @paulebowen.  More case law discussed about observation failings and their relationship with neglect from @paulebowen #JusticeforLB.  PB: Attempt by @Southern_NHSFT to water down and create additional hurdles to {encourage} conclusion wasn’t neglect << @paulebowen.  PB: so you would be directing the jury unlawfully Sir, that would benefit no-one <<< @paulebowen #JusticeforLB.  Coroner ask Fiona Paterson for @Southern_NHSFT to take through her submissions and views related to what we’ve just heard.  FP takes Coroner to Jervis, seems departure from Chief Coroner’s Guidance and Jervis on this point [definition of neglect].  FP for @southern_NHSFT ‘clearly a tension between the Chief Coroner’s guidance and Jervis despite fact they refer to same case law’.  FP: wish to assist the jury not deflect them from a failing that the Trust @Southern_NHSFT concede should be before them #JusticeforLB.

FP for @Southern_NHSFT requests the Coroner to agree ‘in ordinary English a gross failure is one that is very serious’  Hear that @paulebowen doesn’t agree with any of his learned friend’s submissions for @Southern_NHSFT but pleased she agrees to very serious.  FP for @Southern_NHSFT suggests that ‘clinical negligence itself does not amount to neglect’ #JusticeforLB.  FP: If aggregation of failings is put before the jury they must be able to point to series of failings not just concern about aspect of care.  FP for @Southern_NHSFT ‘jury must look at evidence available at time not one transpired since Connor’s tragic death’ #JusticeforLB.  FP @Southern_NHSFT ‘I agree keeping proper observations when LB was in bath cld amount to basic medical care’.  FP for @Southern_NHSFT ‘jury have to go through the step of finding failure of observations… not be helped to find it’.  FP: It’s the @Southern_NHSFT position but you’ve now made a ruling in relation to training.  Coroner confirms training and guidance.  FP for @southern_nhsft: Neglect has to be linked to central issue of the case, how did Connor {come to} be left to bathe alone behind a closed door.

Coroner wants to make some decisions fairly shortly, worried its getting unwieldy – other counsels asked for any submissions.

Oliver Williamson for Dr Jayawant agrees on wording of ‘very serious’ for gross.  OW concerns about how jury deal with contributing factors @lbinquest #JusticeforLB.  OW suggests ‘was there a failure in the systems in place that caused or contributed to the death’: Yes, No or Can not decide.  OW wishes heading ‘other issues’ not ‘other failures’; suggests wording for questions to be put before the jury #JusticeforLB.  OW wishes the jury to be asked ‘whether there was a failure…’ to not lead the jury #JusticeforLB.  Recap by @paulebowen.  Agreed: accept very serious is the test, shouldn’t mention simple clinical negligence and accepts the aggregation point.

Now @paulebowen more case law; test in relation to gross negligence manslaughter so odd for neglect to have more stricter test of causation.  3 separate tests in case law: clear and direct causal link, more than minimal/trivial test, material contribution test << @paulebowen.  Coroner wishes to combine two tests; @paulebowen and Fiona Paterson for @southern_NHSFT both object to suggestion, believe will confuse jury.  PB: Clear and direct causal link test does not appear anywhere in relation to Article 2 cases.  For Article 2 cases you don’t even need balance of probabilities.

Coroner requests a draft of these points before ruling; if he thinks will cause confusion he’ll revisit #JusticeforLB.

Move on to discussion around phrasing of words on system failure.  Agreed @paulebowen will sit down with Oliver Williamson and agree a form of wording to suggest to the Coroner #JusticeforLB.  Discussion on how expert evidence is considered; Alan Jenkins restates Prof C is not a psychiatrist and hasn’t worked on STATT.  Alan Jenkins, counsel for Dr Murphy ‘believes that the expert witness is offering opinions outside her field’.  AJ believes there is dispute about expert witness evidence.  OW doesn’t want jury advised that they ‘must accept her opinion’ @paulebowen suggests wording ‘it’s a matter for them [jury] to decide’.  Michael Fortune for Winnie Betsva queries whether the jury shd give reasons if they are to depart from the evidence of Prof Crawford?  Other counsels disagree for it’s inclusion, MF: ‘I clearly have no support at the bar for this’, so it’s dropped.

Discussion around advice to jury on narrative in an Article 2 case; shd avoid words such as careless, reckless, negligence. PB: In an Article 2 case you must be able make judgements of factual nature Coroner: shd be brief and factual without naming individuals.  Further discussion re how the Coroner will sum up; jury to have their lunch, we’ll resume legal submissions at 12:30 and jury return at 1pm.

***

Legal discussions continue amongst legal counsel @LBInquest, then the Coroner will return to discuss and agree and then the jury will return.  Coroner back in for further discussion over what direction and form is given to the jury @LBInquest.  Directions to the jury agreed; agreement on wording ‘more than minimally negligibly or trivially contributed to the death’ #JusticeforLB.

OW argues jury should be reminded of key aspects but not forced to reach a determination on each of them #JusticeforLB.  PB would like the jury to be directed to give an explanation for their answer, not just answer yes or no: in answering bear in mind…  FP for @Southern_NHSFT would like the jury to be invited to give an explanation but not be required to.  FP concedes the law is with @paulebowen and Coroner agrees so jury directions and form will be finalised and jury return in 5 mins @LBInquest.