The Irresponsible Clinician.

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#justiceforLB, Connor Sparrowhawk, GMC, High Ordeals, JusticeforLB_GMC, learning disability, medication, mothers, NHS, preventable deaths, Sloven Health, true stories

Revolting reminder yesterday of the complete lack of empathy and human kindness manifested by LB’s so-called Responsible Clinician, via her brief, at his inquest.

The psychiatrist, Valerie Murphy, is up in front of the GMC’s fitness-to-practice Panel this week and next.  Confusingly, the GMC has decided to refer to LB neither by his name, Connor Sparrowhawk, nor his nickname of LB, but as ‘Patient A’.  There’s probably a whole other blogpost in there about the effect and intentions of this depersonalisation, but right now I am busy with other things.

The full list of allegations runs to four pages (thanks and acknowledgement to George Julian for posting these).

On a first count, there are 55 separate allegations there, of which only the first does not allege misconduct.  But the effect of 7 (i) and 7(ii a-c) is to multiply the accusations in 7(a)-7(f).  Item 7 contains 24 separate allegations of misconduct, giving a grand total of 68 allegations of individual instances of Murphy’s care of LB falling below adequate standards.

Of those 68 allegations, Murphy has admitted 30, which are accordingly found proven, but contests the remaining 38.  Looking at the matters admitted to, they are either procedural failings (not arranging a best interests meeting, inadequate record-keeping) or related to Connor’s epilepsy.  The ones she is contesting are the mostly psychiatry-related ones: assessment, diagnosis, treatment and medication, including the whole of that multiplex Section 7.

The inference I draw from this is that she intends to assert that her treatment of Connor as a psychiatric patient was unexceptionable, that its poor documentation was down to faults in the system beyond her reasonable control, and that his physical health was not her responsibility.

At Connor’s inquest, she was already citing system chaos, for example on the morning of Day 6:

VM: I can’t remember what was seen or discussed at that meeting, but I remember it as quite chaotic..

11.05  AS asks who those minutes wld be sent to?  VM: Wouldn’t know.  AS: Do minutes of CTM meetings find themselves in patient’s medical records?  VM: Yes, they would.  AS: Would members of the team have a duty to ensure those records were accurate as medical professionals?  VM: It depends, we were struggling w RiO, the Chair would read and confirm them.  

(From @LBInquest tweets)

Now, I’m all for Southern Health management being made to shoulder their share of responsibility.  It was painfully obvious at Connor’s inquest, that the detached and indifferent nature of Southern Health’s oversight of Oxford services was itself probably well over the line of neglectful, leaving staff demoralised and demotivated.  But Southern’s flaws, however egregious, do not excuse a clinician failing in her direct duty to a patient.

The failure properly to treat Connor’s epilepsy is catastrophic on its own.  Psychiatrists are medical doctors, and all medical doctors are required first to train as generalists before they specialise.  Moreover, Murphy is a specialist in the psychiatry of learning-disabled people.  Given that epilepsy is commoner among learning-disabled people than it is in the general population, she should have been well aware of epilepsy in general. And, given the information that came into STATT with Connor and the subsequent additions to that information offered by his family, she should have focussed on epilepsy as a difficulty of Connor’s in particular.  Instead, she dismissed it, and continued to do so.

On Day 5 of LB’s inquest in 2015, she insisted that “there was no evidence of seizure activity during LB’s admission”, because “two instances that were explored as potential seizures….were ruled out”.  This was in spite of clear and urgent warnings, both oral and written from LB’s mother that she had seen signs of seizure activity – drowsiness and a bitten tongue – while LB was in STATT.  Now, it seems, Dr. Murphy has folded on the epilepsy in the face of the inquest findings, although, oddly, she still appears to contend that she obtained a history of Connor’s epilepsy that included whether seizures made him tired and need to sleep.

My general feeling for the other contested allegations is that these are areas where it is possible for Murphy to argue that she did the things she should have done; it is merely her recording of them that is defective.  Slap-on-the-wrist stuff, not striking-off material.  Whether those arguments will seem plausible, is likely to be largely down to the credibility of Murphy herself.  She needs to present herself as competent, knowledgeable  and benevolent, but overworked and harassed.

Hence, no doubt, the utterly disgusting hounding of Connor’s mother in front of the Tribunal yesterday.  The interactions of Richard Partridge, Murphy’s barrister, with Dr. Ryan, were not so much a cross-examination as an attempted crucifixion.  He did everything he could to portray Dr. Ryan as incompetent, ignorant, uncaring, shiftless and vindictive.  It was exactly the same strategy as the one used at Connor’s inquest by Murphy’s then-counsel, Alan Jenkins.  It failed then and it failed this time, for the same reasons as before.  Firstly, Dr. Ryan is a person whom it is difficult to impugn: she has always been shrewd, informed, capable, industrious and warm; and now she is showing tremendous courage in the face of loss and grief that would overwhelm most people.  I don’t think a Panel with even a modicum of intelligence is going to fail to notice the discrepancy.  The inquest jury certainly were not fooled.  Secondly, and far more importantly,  Dr. Ryan’s personal characteristics are completely irrelevant to the question of the adequacy of Murphy’s care of Connor.  Whether Murphy found Dr. Ryan’s outspokenness uncongenial, difficult or even frankly insufferable, that was still no excuse to ignore the information she contributed about Murphy’s patient, Connor.

That both Murphy’s briefs have taken this line of personal attacks upon the patient’s mother, suggests to me that the initial steer in that direction comes from Murphy herself.  It seems like a risky strategy.  It’s going to be hard for her to come across as competent when she has so seriously misjudged Dr. Ryan as well as Connor himself; or as benevolent when she has allowed her barristers to stick so many unwarranted knives of sneer and innuendo into a grieving mother, and then twist them.

The nadir yesterday came when Partridge read out Dr. Ryan”s impression of Murphy as ‘dismissive, arrogant and distant’ and told her it was ‘very upsetting for Dr. Murphy to hear any patients relative describe her as such’.  Dr. Ryan asked for a recess at that point:

” ‘Dr Murphy is upset by your evidence.’ Dr Murphy is upset. Upset. ‘Can I have a break?’ I was taken to a room alone. To howl…“

Nevertheless, she returned to display the intellectual rigour that #JusticeforLB’ers have come to know and admire.   Pursuing an irrelevant line of questioning on the blog, Partridge tried leading his witness: ‘The tenor of the blog was critical, in a neutral term’.

“I don’t think ‘critical’ is a neutral term,” rejoined Dr. Ryan.  “The blog was an honest account of our experience.”

Partridge continued in a similar dismissive vein, referring to ‘the tongue-biting incident’.  When told by Dr. Ryan that it was not an ‘incident’ but a seizure, he went DefCon1 on the patronisation:  ‘I know that you feel it was a seizure.’

Dr. Ryan did not let him get away with that, either. “It was a seizure.”

I really don’t know what Murphy hopes to gain by permitting or requiring her counsel to act thus.  If anything could confirm the accuracy of Dr. Ryan’s negative summation of Murphy’s character, it surely has to be such a display of tone-deaf, compassionless persecution.  To  ‘dismissive, arrogant and distant’, most observers would probably add, ‘egocentric, devoid of empathy, cruel and disrespectful’; in short, thoroughly unsuited to being a consultant psychiatrist.

An irresponsible clinician.

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Brief and Briefer : Justice4LB@GMC.

Tags

#justiceforLB, Connor Sparrowhawk, GMC, JusticeforLB_GMC, preventable deaths, true stories

The General Medical Council’s Fitness to Practise hearing into the conduct of Dr. Valerie Murphy (LB’s consultant psychiatrist – and Responsible Clinician – at the STATT unit where he died) began at 9.30 this morning. It’s taken over four years to get to this point; shortly after LB’s drowning in the STATT bathtub, Dr. Murphy upped sticks and headed back to her native Ireland, where she has continued to practise. 

I’m pretty uninformed about GMC procedures, but it appears that the Fitness to Practise Tribunal acts in a quasi-judicial manner.  Three people – one legally qualified, one medically qualified and one a lay representative – act as the judge-and-jury panel, while the GMC acts as prosecutor and the doctor as defendant. Parties complaining of being injured by the doctor’s actions are kind of off to the side as witnesses.

Both the GMC and the doctor get to instruct counsel.  Witnesses don’t; it is the GMC’s legal team who have to look after patients/complainants.  Fortunately, the GMC’s solicitor seems to have been entirely as considerate as one could wish of LB’s family, and one hopes that the GMC barrister will be equally considerate of LB’s mother, Dr. Sara Ryan, when she comes to give evidence.  One also hopes she will block the kind of disgraceful personal attacks on Dr. Ryan that Dr. Murphy’s inquest counsel indulged in, should anybody attempt to follow his example.

At today’s hearing, the Tribunal chair did introductions and housekeeping.  The GMC barrister made an opening statement outlining the case against Dr. Murphy: the events in STATT; the first Verita report; the inquest findings; and findings from the investigations of the GMC’s expert witness.

Dr. Murphy’s barrister corrected a couple of minor errors regarding designations and dates, and suggested that the Verita report was possibly irrelevant and unspecific.

The legal bundles of paperwork – two lever arch files apiece – were distributed to the Tribunal panel members, and they retired to read through them.  Evidence from witnesses will be not be heard until tomorrow.

And that was it. The public part of the hearing for today was all done and dusted in about an hour.  The briefs were brief indeed.  I hope the GMC solicitor had told Dr. Ryan that was likely to happen.

Imagine re-reading and re-re-reading all the evidence – the reams and reams of excruciatingly painful evidence – about your son’s death.  Imagine it having this effect on you.  Imagine psyching yourself up to do what was necessary, once more, to hold accountable the person who, above all others, could have put in place the precautions that would have avoided that death.  Imagine turning up at the Tribunal and seeing that person face-to-face again.  Imagine if you expected, that you if you could hold it together until 5pm, your part would be all over. And then imagine being told, without warning: Not today; come back tomorrow.

I hope it didn’t happen that way.  I do hope that warning wasn’t omitted.

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).