• About

Who By Fire

~ High ordeals and common trials

Who By Fire

Tag Archives: preventable deaths

Rules and Guidelines

04 Mon Mar 2019

Posted by Kara Chrome in Uncategorized

≈ Leave a comment

Tags

#justiceforLB, Connor Sparrowhawk, Eddie Stobart, preventable deaths

Can’t help feeling slightly sorry for the Eddie Stobart PR/comms people (whether it’s the lovely Bonnie or someone else) when they come into work this morning and see what’s been happening on the company Twitter timeline over the weekend.  Here’s hoping they feel love-bombed rather than battered.  And a mea culpa from me, as I’m about to add to the heap of waiting messages.  You see, I wish to resile from my suggestion of Elle Bea as an alternative to Connor Sparrowhawk.  Since I posted A Cab For Connor on Friday, it’s become evident that the ‘Stobart lorries carry female names only, no surnames, no nicknames’ rule is not actually a rule, it’s a guideline that’s been bent or bust on several previous occasions.

The first time of which I’m (now) aware was in 2005, when a cab was named Optimus Prime, to celebrate 20 years of the Transformers. While dear old Optimus comes from a C/Fe culture that seems heavy on the Fe and light on the C, and is therefore probably not gendered, it’s equally obvious that they (a plural pronoun seems appropriate for a multiform entity) have been assigned male by Hasbro and the film companies, and accepted as such by the Stobart company.

At some point thereafter, a truck was named Valentino.  This was apparently after ‘Italian racing legend Valentino Rossi’, a motorbike racer who has had the distinction of winning world titles in four different classes (rather than the fashion designer or the silent film star), but I can’t find any further rationale for this decision.

The third truck, on the other hand, Lee James Rigby (2015) breaks both the ‘no males’ and the ‘no surnames’ guidelines, for the best of reasons.  The fusilier, who was murdered in 2013 while LB was still in the STATT unit, had hoped to become a Stobart driver once his service days were over, alongside his father, also a driver for the firm.  It’s a great credit to the firm that they would honour Lee and support his family, by making an exception to their naming guidlines in his memory.

So I hope the decision-makers at Eddie Stobart will now pronounce themselves in favour of Connor Sparrowhawk, as

  1. There’s precedent for the use of male names, and of a surname.
  2. Connor loved Eddie Stobart lorries and felt a deep connection to the firm, which has been passed on to the people who have come to know him since his death.
  3. Connor, like Lee, died a needless and unjust death, and deserves to be remembered.
  4. It would be a wonderful thing to do for his family, who have suffered continuing injustices following his senseless – because preventable – death.
  5. Connor Sparrowhawk is just such a fabulously cool name.

Looking forward to hearing from you, @EddieStobartCom. Hope you’re all having a good Monday and that you feel a well-deserved glow of pride in doing Connor proud.

All the best

Kara.

Injustice For LB.

24 Sat Feb 2018

Posted by Kara Chrome in Uncategorized

≈ 1 Comment

Tags

#107days, #justiceforLB, (un)accountability, Connor Sparrowhawk, High Ordeals, learning disability, preventable deaths, Sloven Health

The MPTS hearing concerning the fitness to practise of Valerie Murphy, the psychiatrist who was the (ir)Responsible Clinician at STATT during LB’s (Connor Sparrowhawk’s) time there, finished on Wednesday 21 February.

Having made a determination of facts in August 2017 and a determination of impairment in the November of the same year, the Tribunal reconvened on 19 February to deliver its decision on sanction.

It’s worth remembering that when Murphy appeared in person at the August hearings of fact, her attitude was the mixture of disdain and belligerence she had manifested at LB’s inquest. She did not appear in person at the November impairment hearing. Questions were put to her counsel, Richard Partridge, who answered them as best he could in the absence of his client, which was not terribly satisfactorily, as it turned out. There was quite a lot of ‘I will have to ask’ and ‘I will find that out for you, Madam’ from Mr. Partridge. Some documentary evidence of her remediation was produced. The Panel seemed to consider her moves towards insight and remedy pretty perfunctory:

Remediation

So three months later, Murphy’s counsel presented a bundle of additional evidence by way of mitigation, consisting of

• Emails regarding the ‘yellow card’ (actually an A4 form for recording details of epilepsy);
• An audit of Epilepsy In Psychiatric Inpatient Settings (a ‘baseline’ audit);
• An audit of the epilepsy ‘yellow card’;
• An email regarding epilepsy care;
• An email regarding Directions for Future Research; and
• Testimonials;
• A reflective statement, signed and dated 15 February 2018 (the Thursday before the sanction hearing began);
• A certificate of attendance at ePEX (An Electronic Computerised Record Keeping System) training;
• An ePEX Manual and Index;

The more I re-read the @JusticeforLBGMC tweets, the more sickened & disgusted I feel. Murphy has never apologised to or shown any consideration for Connor’s family, but she has used his death to set herself up in southern Ireland as an expert on epilepsy in learning disability care.

She claims to have had an epiphany after Connor’s inquest & begun her ‘yellow card’ epilepsy recording scheme. She says she was open with other health workers about her failures, in order to emphasise the importance of epilepsy care and the dreadful consequences of her failure to provide it. But until the 19th of February, she hadn’t ever publicly acknowledged the full extent of her failings. Even on Monday, she was giving deflective answers to questions about the extent of her responsibility for Connor’s death and skirting round her previous efforts to displace blame onto the nursing team. How can she possibly have been honest with colleagues about her errors at a conference in June 2017, when in August 2017 she was stoutly refusing to be accountable for them? From here, the ‘yellow card’ scheme and the conference look like something cobbled together as extenuation, just in time for the first MPTS hearing.

Murphy’s submitted email featured three other clinicians, showing, she claimed, that she was ‘driving the (epilepsy) scheme forward’. I’m not sure you can call this bunch a steering group for the scheme, as the participants mentioned have never met as a group and there didn’t appear to be any formal agreement on working to ensure that the scheme is uniformly implemented. In fact, it turned out that of 3 other people mentioned in the emails, she’s not seen one since 2014, and another since around 2015. However, she said, she sees the third person frequently. How frequently? asked the GMC barrister. Oh, all the time, said Murphy. This is likely to be true. The frequency of contact does not, however, constitute evidence of assiduous devotion to working on the yellow-card project. Although they do not share a surname, the third person is Murphy’s spouse.

Moving on to the ‘yellow card audit’ data provided, this came from Ireland’s Midwest health region. The Midwest region, for those whose Irish geography is a little sketchy, is Limerick and its hinterland. As it happens, the University of Limerick is where Murphy’s husband is based, as an Adjunct Senior Clinical Lecturer in psychiatry with an interest in research. In fact, he is the one who appears to be running the whole Midwest ‘yellow card’ project. Murphy did not make an upfront, public, competing interests disclosure about his involvement in the audit process.
The abstract of the poster presenting the Midwest audit says that the introduction of the ‘yellow card’, coupled with ‘an intervention to improve awareness of risks’, significantly improved documentation of considerations concerning assessment and risk assessment, but did not significantly improve documentation of PRN (as-required) epilepsy medication.

In Cork, no auditing was done because Murphy has been off work since August 2017. She did, however, claim that “I’ve had verbal feedback that shows 100% use and completion of yellow card for a patient in the unit there, the feedback I get is that it’s working.”
I don’t see how such claims can be considered evidentially admissible in the absence of robust numerical data, especially if – as I suspect – this was oral, i.e. unwritten verbal feedback. Murphy’s word for it was, at best, hearsay. There was no way of verifying the accuracy of either her understanding of what was said or her transmission of that understanding. She produced nothing to corroborate her story.

Having been castigated for failings over recording notes on STATT’s RiO electronic system, Murphy has taken a course on e-notation. She still doesn’t use electronic notes, but if she did, she would hand-write notes & then transfer them onto computer. I can see more than a smidge of potential in that for transcription errors and omissions.

Murphy ducked directly answering questions about her failures in leadership , leading to dialogues like this:
GMC barrister: You just explained a moment ago this document was your reflection following (LB’s) inquest, is that right?
Murphy: Yes
GMC barrister: You outline leadership as one of the aspects.
Murphy: Yes.
GMC barrister: Do you accept you were trying to blame the nursing (staff) for deficiencies?
Murphy: This is a reflective document about my thoughts and feelings of why I struggled with leadership, this is very personal, part of reflecting on things was thinking what was stopping me, why, this was more a reflection of my difficulties with the environment.

Ah, that inconvenient, uncongenial environment. Of course.

Chloë Fairley, for the GMC, pressed on:
Fairley: Do you accept that you don’t at any stage identify your own failings in this document?
Murphy: Yes.
Fairley: Do you accept you’re attempting to lay some of the blame on the nursing (staff)?
Murphy: No, someone has to take charge. Sorry, I’ve got a bad headache. It was the inquest that was helpful for me, for it to sink in that (the care system) was siloed and there was no-one tying it together, and it should have been me that was doing that.

Murphy claimed to have questioned Southern Health’s interdict on contacting Connor’s family. I don’t doubt that Sloven imposed just such a prohibition on direct contact. Yet doctors have a duty of candour, so Murphy’s abiding by that embargo was dubious, to put it mildly. Moreover, even after leaving Southern’s employment in 2014, she made no attempt to contact or comfort LB’s family. Instead, Murphy continued to treat his mother in particular in a hostile and aggressive manner, via her legal representatives at both inquest and tribunal

She contradicted her own evidence: having previously claimed she was distracted by a multiplicity of clinical roles, she then admitted she was no longer doing them when Connor died. She also made statements that contradicted the submissions made on her behalf by her counsel: she claimed to be a ‘young consultant‘ while her counsel talked of ‘a single clinical incident in a long career.’
Nobody acknowledged that the failings in this ‘single clinical incident’ had stretched out over a span of #107days.

Finally, her counsel submitted for Murphy that she was ‘emotionally broken by these events’. Given that plural, ‘events’, I don’t think it was Connor’s death that broke her. I believe it is being held (repeatedly) to account, that she has found shattering. Had Connor’s death affected her, she could not, would not, have countenanced her barristers hounding his mother as they did. If she had come to realisation after the inquest, as she claimed, she would not have permitted the same specious attacks on Dr. Ryan to continue at the tribunal. As with the Tribunal’s finding on impairment (page 15, paragraph 69) when it considered the extent of Murphy’s remorse, the brokenness of Valerie Murphy seems ‘limited to the consequences these (Tribunal) proceedings have had upon her.’

Despite the dubiety of some of her evidence, despite being granted an extra seven months in which to work up a show of remorse that was still unconvincing, despite the bad faith she displayed in the way she allowed her lawyer to batter LB’s mother, despite the inapt-to-the-point-of-grotesque intervention of her witness Prof Ted, despite her inability to use health information technology, despite one-minute-to-midnight reflections extruded four years and eleven months after Connor went into STATT – her sanction is a 12-month suspension, (which may be extended at a further review before it expires). The tribunal accepted Murphy’s assertion of a ‘sea-change’ in her attitude. It even quoted her own marine-metaphor description of herself, verbatim.

I can’t give this change much credence and I really don’t know how anyone can ever place confidence in her again. Her character seems entirely unsuited to responsibility for or authority over disabled persons. Its salient features appear to be cowardice and dishonesty. Her behaviour towards Connor’s mother during his time in the unit reeks of both. Murphy would neither confront Dr. Ryan with her own view of events, where her view and Dr. Ryan’s were in disagreement, nor would she keep Dr. Ryan apprised of what was actually happening to Connor. After Connor died, Murphy didn’t act on her duty of candour and she made repeated proxy attacks on Dr. Ryan via her lawyers.

One of the reasons I don’t believe that Murphy has overcome either her cowardice or her dishonesty is embodied in this thread of live-tweets from the sanctions hearing. Dr. Murphy explained she was honest with people about her learning before describing the ‘yellow card’ scheme.

Cork 100

What would ‘honesty about learning’ look like? Well for a start, it would have to acknowledge the trigger for the learning: the death of Connor Sparrowhawk and Murphy’s responsibility for that death. True honesty would have to be along the lines of the penitential act:

I confess…to you, my brothers and sisters
that I have greatly sinned
in my thoughts and in my words
in what I have done
and in what I have failed to do
through my fault
through my fault
through my most grievous fault…

So we come again to the ‘insight’ and accountability question: Did Valerie Murphy admit to the professional colleagues to whom she presented the ‘yellow card’ scheme, that, through her ignorance, arrogance and failure to fulfil her duties, an eighteen-year-old-boy for whom she had clinical responsibility came by his death under her care, drowned in a hospital bath? I beg leave to doubt it.

The original article proposing the scheme, a letter to the editor of the Irish Journal of Psychological Medicine, dated January 2017, doesn’t mention Murphy’s experiences at all. Connor is expunged from the narrative. What we have here is a detached, academic suggestion from our cogitative clinician, worrying about what appear to be non-specific risks of ‘higher mortality rates, particularly in those with recent seizures‘ and ‘psychiatric medication (that) may interact with anti-epilepsy medication‘ or ‘seizures could be mistaken for evidence of psychiatric illness‘ and – a real kicker here – the fact that ‘from a risk-related viewpoint, those with comorbid epilepsy have specific risks to consider including but not limited to areas such as bathing…‘

Every individual statement is neatly referenced, either to an academic paper, or to some other authoritative publication. Far from presenting the ‘yellow card’ scheme as an act of atonement, Murphy is presenting herself as a paragon of farsighted benevolence who has sagaciously synthesised all this disparate observation into a coherent and philanthropic whole, to improve the welfare of the afflicted. In the case of the risk consideration, Murphy has the gobsmacking neck to refer to the UK National Institute of Clinical Excellence epilepsy management guidance. You know, that commonsense stuff about deep water and seizures that she fatally ignored when Connor entered her orbit.

Of course, Murphy would have needed to seek permission from his mother to talk about Connor. She would have had to approach her humbly and frankly: “I realise I did a terrible thing – a series of terrible things – when your son was in my care and after he died. I was neglectful towards him and I’ve been vile to you. I am sorry, although I know mere words are not enough. Nothing I can do will bring him back. I wish beyond anything that I had done things differently. I have had this idea for trying to help other doctors do things differently, I hope it might prevent failures like mine in future and avoid deaths. May I send my ideas to you? I won’t do anything without your agreement or approval….”

But it’s beyond Murphy. She doesn’t have the guts, or the integrity, to go beyond mere remorse to contrite action. She’s happy to wallow in regret, to which she now appears to have added a splash of guilt (I don’t believe the tribunal’s interpretation of her demeanour to mean that she is ‘wracked with guilt’, is correct. Wracked with regret – for herself – sure; guilt-wracked: No.) She has made no amends to Connor’s family. She hasn’t even apologised to them for inflicting some of the deepest hurts one human being can cause another; she’s half-apologised – after prompting – to the Tribunal.

There comes a time when apologies and amends are no longer acceptable. They are too late to be credible. I don’t know if Murphy has reached Connor’s family’s Too Late, although given that Murphy’s barrister harried Connor’s mother into breakdown and illness at the MPTS fact-finding hearing, I wouldn’t be surprised if their Too Late were last August.

On the other hand, I don’t foresee Murphy ever making true effort at apology. As I say, she has, in my estimation, neither the backbone nor the probity for it. She’s interested in (self)-justification. Not justice.

Shitstorm.

25 Thu Jan 2018

Posted by Kara Chrome in Uncategorized

≈ 6 Comments

Tags

#HandleyInquest, 'supported' living, coroner, court proceedings, Down syndrome, family, human rights, motherblame, NHS, preventable deaths, siblings, true stories

Right, you lovely lot, a few words, please. The ones from this book, mostly:

You may have noticed I indulge in the occasional sweary. Not desperately frequently; I was brought up to euphemise rather than curse. (My sister once acquired a boyfriend whose father turned out to be a Church of England vicar. My parents invited him and his wife to dinner; I was in the middle of a story – indeed the middle of a word – when my gentility reflex kicked in on autopilot:
“… and when we came out it was absolutely piss-sisting down…”. The boyfriend, who was a squaddie, burst out laughing. His father eyed him sternly. “Don’t you try that, son; you don’t have the aplomb to carry it off.” My Dad suppressed a grin; my mother looked bewildered.)

To be honest, I’m not much of a one for the f-word, except under extreme provocation. I don’t have the right accent for fluent and habitual use, especially in writing. I don’t care for the c-word and other specifically female words used as terms of abuse. Females are subject to far too much abuse in general, without having bits of their anatomy used as synonyms for ‘vilest shame’. It’s for much the same reason that I object to racist abuse or the r-word and all its nasty ex-medical cousins. But bloodys, arses, bastards – you’re welcome. And of course, my favourite, the excremental expletive in all its forms. Shit shite shitty shitey crap.

I’m sorry if it offends you, and can only suggest that if you are discommoded by it, you craft yourself a virtual clothespeg for your mental nose, because for the next three weeks this blog is going to be neck-deep in the stuff, in forms both literal and metaphorical, conceptual and weightily material, temporal and behavioural. And the shitty behaviour, I can tell you now, is not coming from people about whom behavioural concerns are usually expressed.

This is the story of the life and death of Richard Handley, whose inquest started on Monday in Ipswich. A life pervaded, shaped by and ultimately lost to shit; and where the dishing-out of shite, particularly to Richard’s family, didn’t stop with his death.

Richard was suspected from an early age of having a condition called Hirschsprung Disease, where the person lacks fully developed motor-nerves to part of their bowel (usually the lower end of the large intestine, near the anus). Wherever the nerve-endings, known as ganglions, have failed to develop, the gut cannot properly push digested food along; the nerveless areas do not relax normally to allow for its passage. As a result, the affected portion tends to contract, leading to a build-up of faeces above the narrowed area. Stool that hangs around in the guts for any length of time loses water and becomes hard, making it even more difficult to push out. After a while the hard stools can become ‘impacted’: cemented together in a solid mass that stretches (‘distends’) the bowel like an overfilled balloon. Sometimes, liquid faeces will seep around the blockage, giving the impression the person has diarrhoea rather than constipation. It’s vital that people at risk of impaction eat high-fibre foods, drink plenty to keep their stools soft, take stool-softening and laxative medicines if needed, and have enemas to wash out turds if they are not able to take a daily dump. Otherwise, the blockage can back up until their guts are filled end-to-end, swollen with rock-solid shit that presses on and squashes other organs, interfering with or damaging those other organs as well. Sometimes, bits of bowel can become so stretched or squashed that they lose their blood supply and die off, leaving a hole in the gut (‘perforation’). This is life-threatening.

To make a definitive diagnosis of Hirschsprung Disease, doctors look at X-rays of the person’s bowel to see if there are restricted and distended areas, and do an operation to take a small sample (‘biopsy’) of the lining of the gut at the point where it narrows. They then examine the sample to see if the ganglion cells are missing.

Hirschsprung Disease is rare. It affects more men than women, and it’s commoner among people with Down Syndrome than among the general population. Richard had Down Syndrome. He also had moderate to severe learning disabilities. His local hospital, James Paget in Lowestoft, advised after X-rays in 1998 that Richard should have a biopsy to see if he had Hirschsprung disease. Eventually, the clinicians decided against it, partly because they felt that the procedure was potentially distressing and/or physically risky for Richard, partly because they did not have suitable laboratory facilities for preparing the sample for examination under a microscope, and partly because Richard’s family managed his poo problems superbly, though a combination of diet, medication, bathroom physiotherapy, and turning the unpleasant aspects of his condition into fun for Richard.

Richard had a keenly developed sense of humour. He liked Mr. Bean, slapstick and visual humour, toilet and fart jokes. His family accompanied him on visits to the lavatory. “In order to have a bowel movement,” explains his mother, Sheila, “Richard needed his mind taken off what was happening, so he could relax and let go. That was the point of the games and physio. The games were things like throwing something in the air so he reached to catch it and giggled at the game. It meant he relaxed and wasn’t worried about going for a poo or if it might hurt.”

In spite of this careful management, in the late 1990s, Richard needed hospital procedures on several occasions to empty his bowel and to try to prevent future problems. At around the same time, his behaviour deteriorated and he was referred to psychiatry by the Learning Disability nurse because he was refusing to get out of bed, he was incontinent and he appeared scared. The psychiatrist diagnosed Richard with a depressive illness with psychotic features. Various professional people noted that the acceptability of his behaviour went up and down, as did the swelling of his belly. No-one seemed to wonder at this time if there might be some sort of physical-to-behavioural causative link. I don’t know about you, but if I had a bellyache and kept involuntarily soiling myself, I might be quite inclined to take to my bed and get snarky with anyone who tried to winkle me out of it for what seemed to me to be no good reason. But then I don’t have a learning disability, so people would have to look for some other explanation than ‘learning-disability-related mental illness’ for my sudden change in bedroom and bathroom behaviour.

Richard went into respite care in 1998 and then in late 1999 into a residential home. As part of his placement, he had a Statement of Health Needs, which specified ongoing/diligent monitoring of bowel function and management as part of his primary and secondary care needs and identified maintenance of bowel management programme as part of his non-negotiable, quality-of-life needs. Richard was given medication to treat his mental-health difficulties. Although some of these medicines had the unfortunate side-effect of causing constipation, through a combination of diet, medicine, exercise and meticulous (and meticulously-documented) bathroom support, Richard remained healthy and happy for several years. The agreed protocol was that if, in spite of his fibre, fluid and laxatives, Richard failed to have a bowel movement for three days, the District Nurse would be called in to do an enema.

Sometime in the mid-to-late 2000s, Richard’s care was altered. His Statement of Health Needs went into an old file that was no longer referred to. The District Nurse no longer came to do enemas. Initially, this was because his diet and medication meant she was not needed, but even when he began to miss daily poos, she was not recalled. A misunderstanding of the Mental Capacity Act by Richard’s support staff meant he was allowed to make very unwise decisions about the food he would and would not eat, even though he had been assessed on a number of occasions as not having the capacity to make health decisions. Even with support, Richard was not able to understand, retain, use or weigh information relevant to his health in making decisions about his diet. He should have had Best Interests decisions made for him, instead of being left to make choices that transformed his diet from high-fibre, high-fluid to low-fibre, low-fluid. The pursuit of the ‘independence’ agenda for Richard also meant that he was not accompanied to the bathroom any more, and proper monitoring of his bowel habits fell by the wayside. As his food became less and less healthy for his bowels, Richard became more and more unwell. The picture painted by the Serious Case Review of Richard at this time, (here given the pseudonym ‘James’), the ‘cheeky chappy’ who dearly loved a bit of toilet humour, is utterly heartbreaking

Serious Case Review: James (Flynn M & Eley R). October 2015, Suffolk CC SAB.

Around the same time, administrative changes in the Health Service, poorly implemented in respect of Richard, left his psychiatrist as his main medical contact. The psychiatrist did not do physical assessments of Richard and did not liaise with Richard’s GP to ensure that his physical as well as his mental health was being monitored. Both the psychiatrist and the staff where Richard lived interpreted his increasing lethargy, apathy, non-co-operation and poor self care, as mental rather than physical health problems. The staff, who did not have medical expertise, did not realise that Richard’s chronic constipation was not being dealt with by his laxatives, which were causing ‘overflow diarrhoea’: seepage of liquid poo around and past the unmoving solid stools.

In 2010, Suffolk deregistered a number of care homes, redesignating them as ‘supported living’. Richard’s care home was one of these and he signed a tenancy agreement, although his family queried his capacity to do so. The changes were supposed to give ‘service users’ more control over their own budgets, more choice in their activities and more independence. The rebadging also gave Suffolk financial advantages – for example, the newly ‘independent’ tenants were expected to organise their own cleaning; the Council did not have to pay the provider for this any more. The house promptly became untidy and dirty, as the residents were not capable of running a cleaning rota and staff were no longer paid to assist with maintenance. Another area of cost saving was in the inspection régime: while care home providers have to be inspected facility-by-facility, looking at individuals’ care plans, supported living providers are inspected centrally. This less onerous inspection regime was also less expensive. Someone whose health and care management was as complex as Richard’s, really should have had an alternative system of monitoring set up, to look at his individual needs and whether they were being met. Instead, the various people looking out for him – the home staff, GP staff, hospital staff, day centre workers, Richard’s family – were left doing the best they could in their own areas. No-one had an overall picture.

Richard’s family were told his health care would remain the same; they did not know (and had no way of finding out) that his health care and monitoring was already much reduced from the levels specified in 1999. They remained involved and contributing, but were not party to information about Richard’s life when they were not around. Richard limped on through 2011 and the beginning of 2012, his mounting uninterest in life ascribed, at his frequent medical appointments, to poor mental health and possible dementia.

On 10 November 2012, Sheila Handley had lunch with her son. She was worried by his swollen abdomen. The following day, Richard saw his father, who discussed, with one of Richard’s support workers, the grotesque size of his belly. On the 12th, Richard’s parents accompanied Richard and a support worker to a psychiatrist’s appointment. The psychiatrist had a high level of concern about not just the size, but also the hardness of Richard’s abdomen, saying he needed an emergency GP appointment. Richard did not get an appointment on the 12th and on the 13th saw a GP registrar, who did not know his history of constipation, and prescribed a large dose of laxatives, even though Richard had been taking laxatives and stool softeners daily for almost all his life. The psychiatrist, meanwhile, arranged an ATU admission for Richard, to address his declining mental health. On the 14th, Richard was taken to the ATU. He seemed unwell: pale and withdrawn. On arrival, Richard had the usual admission examination, and the state of his belly so alarmed the ATU staff that in the evening, he was transferred to A&E. He was found to have massive abdominal distension; his rectum was impacted with faeces and and an X-ray showed his whole colon was distended with impacted faeces.

On the 15th, Mr. Handley senior signed the consent forms for Richard to be examined under anaesthesia. Although the hospital recognised Richard’s lack of capacity, they do not seem to have made best-interests decisions and adjustments to their procedures. Richard was cannulated and anaesthetised under six-person restraint, screaming in terror. 10 kilos of impacted faeces – that’s 1 stone 8 lb in old money – were removed just from Richard’s rectum. When he woke up, he was, unsurprisingly, ‘non-compliant’ with treatment. In his shoes, I think I might have been a touch unco-operative as well. In fact, I’m pretty sure my mental processes would have run something along the lines of, “If one of you white-coated fuckers comes near me again, I’m going to sodding-well BITE you.”

Not that Richard was in much of a state for biting. Although his rectum (the part of his large intestine just above his anus) had been cleared, his colon (the rest of of his large intestine) was still full of solidified shit. He was given drinks but vomited violently and copiously, then passed ‘massive’ amounts of stool but still had a hugely swollen belly. Twenty-four hours after his operation, Richard’s vital signs were decline; his breathing became ragged, his heart-rate was irregular and he had not peed since he came out of theatre. He was catheterised. His oxygen saturation continued to deteriorate. Another X-ray showed his colon was blocked and his small intestine was also jam-packed. Both were pressing upwards into his chest, restricting his breathing. This pressure was also the likely cause of his vomiting; what he was vomiting was faecal matter. He needed to have his guts cleared out more, to take the pressure off his lungs. In the early hours of November 17th, the ITU consultant was called in, but before he could begin treating Richard, Richard went into cardiac arrest. Resuscitation efforts failed. By 2.15 a.m., Richard was dead.

On the first day of Richard’s inquest, the court heard from Richard’s mother, outlining his story. The pathologist who did Richard’s postmortem, Dr. Jason Wong, stated that Richard had died of a cardiac arrest, caused by asphyxiation resulting from aspiration of gastric contents that were vomited because of a large bowel obstruction that was in turn due to faecal impaction. In spite of the manual emptying of his rectum and his later passage of ‘massive’ quantities of stool, Richard’s guts were still so full of shit that they interfered with his breathing and caused him to throw up. He breathed some of the vomit into his throat and the main tubes leading to his lungs, and it stopped his breathing. “A description given in a meeting with the family by @IpswichHosp said Richard drowned in his own vomit”, said Sheila Handley’s counsel. “Is that a fair assessment in layman’s terms?”. “Yes,” said Dr. Wong.

Finally, Detective Superintendent David Cutler of Suffolk Police gave an account of his involvement in the safeguarding investigation into Richard’s death and detailed all the possible offences that he had considered – and then discounted – in relation to the events. Nobody had deliberately set out to kill Richard. Gross negligence manslaughter did not apply; there was not sufficient neglect for it to be considered criminal. He asked for an independent expert’s opinion on wilful neglect, but the expert only assessed Ipswich hospital and felt unable to comment on Richard’s care (and later housing) provider, United Response, and other services. The DS identified failings in service co-ordination in Richard’s daily life, and failings in his hospital care, in particular the length of time it took to refer Richard to more senior doctors, but felt that none of these met the Crown Prosecution Service’s evidential ‘Full Code Test’ for prosecution. He considered corporate manslaughter, but felt breaches of the ‘duty of care’ owed to Richard by various organisations were best addressed by regulatory authorities, not the justice system.

I have to say, I don’t hold out much hope for learning by and from regulatory organisations. I’ve encountered plenty of individuals who seem to be doing their best to re-set their personal thinking patterns and expectations, but the overall impression is of fragmentation. Richard’s family told everybody that he needed extra care, but didn’t know – couldn’t have known – that over time, most professionals seemed to have assumed that somebody else was taking main responsibility. In actual fact, there wasn’t anybody who had an overall view and nobody was ensuring that routine care was being done properly. In particular, Richard’s family, the repository and guardians of his life-history, were cut out of the documentary loop, while the information they had so painstakingly collated and transmitted was shelved. Suffering the consequences of ‘memory loss’ by the institutions into which they are moved seems to be a frequent factor in the deaths of people with learning disabilities. It was definitely in play in the deaths of Connor Sparrowhawk, Nico Reed and Deborah Molloy. It seems to have been a factor in the death of Thomas Rawnsley, who was seen by his family shortly before his death to be so poorly that he was falling asleep into his dinner, but whose concerns, arising from their experience of his previous bouts of severe respiratory illness, were dismissed.

Unless the common threads in these (and many other similar, not necessarily fatal incidents) are addressed and remedied by building in system failsafes, I have a nasty notion there will be plenty more deaths attributable to diagnostic overshadowing and to insufficient patience and attention being devoted to learning-disabled people. I checked the online record of the Coroner’s Prevention of Future Deaths report from Connor Sparrowhawk’s inquest. The diagnostic overshadowing leading to death in his case concerned his epilepsy, and the Coroner asked that Southern Health Foundation Trust, in whose (non)care Connor died, reconsider how they managed care for epileptic patients. In early January 2016, Katrina Percy, the then-CEO of Southern, wrote to the Coroner saying that they would send him a copy of their new ‘Protocol for the Safe Bathing & Showering of People with Epilepsy’, then in final-draft form, ‘as soon as it is ratified’. There is still no copy of that Protocol on the Coroner’s website, so anyone outwith Southern who might be looking for some best-practice ideas about Preventing Future Deaths from epilepsy is out of luck. Two years, mark you, after Connor’s inquest and the publication of the Mazars report caused nationwide ripples; and nearly four years after Verita produced the report that first made it officially clear that poor epilepsy care lay behind Connor’s death.

I want to finish this post by looking at how Richard’s mother was questioned on this first day, by Counsel for the publicly-funded bodies. Bear in mind that Sheila Handley, while remaining very much in her son’s life and supporting him closely, had not been formally consulted about his wellbeing for over a decade and was not included in the circulation of Richard’s health documents. Richard himself could not read these, nor relay their contents to his mother, instead relying on his caregivers to manage for him.

Mr. Hugh-Jones, counsel for the GP registrar who attended Richard on 13/11/12 started by questioning Mrs. Handley on the suspected Hirschsprung’s disease and the lack of a formal diagnosis. Tests, said Mrs. Handley, were delayed while it was felt management was adequate.
Hugh-Jones went on to ask about Richard’s verbalisation of pain. These questions actually went to capacity. Mrs. Handley steadfastly reiterated Richard’s difficulties with comprehending consequences, adding that explanations were, however, useful in securing Richard’s compliance with treatment.
Hugh-Jones asked questions about the notes from the visit to the psychiatrist on the 12th, suggesting that these showed family concern was misplaced:
“…tummy looks better…” “It says tummy looks bigger,” corrected Mrs. Handley.
He queried her recollection of events: “The carer says <the psychiatrist> didn’t touch the tummy.” Mrs. Handley remained poised and dignified. “I don’t think that’s right. My recollection is that he did,” she said.
Hugh-Jones queried Mrs. Handley’s drawing of inferences around the state of Richard’s abdomen in the week before his death. “You weren’t there on the Tuesday when Dr Tajammal saw Richard, were you?” Mrs. Handley permitted herself a touch of asperity. “To be asked to comment whether <his tummy> was static or progressing, I’m getting very confused. He was very distended on Monday and Wednesday, he didn’t lose that distension on Tuesday, if that’s what you’re suggesting? That’s not how it works.”
Mr. Hugh-Jones came back swinging on Richard’s breathing problems: “When you saw Richard on Wednesday he was breathing perfectly normally wasn’t he, so we know it’s progressive?” “Yes,” said Mrs. Handley. Counsel appeared not to process this. “We know he was suffering respiratory symptoms by Wed 16 Nov, we know it was progressive,” he said, adding, “However you might want to shy away from that.” Mrs. Handley neatly sidestepped the insinuation and landed a flush hit: “I’m not wanting to shy away from anything, I’m very much in agreement.” Hugh-Jones seemed slightly flustered by this and proceeded to get Mrs. Handley to flip back again through the bundle so he could query her concerns around Richard’s proposed discharge.
The @HandleyInquest tweets from George Julian record the exchange as follows:
HJ: Were you in the hospital on the morning that Richard declined? SH: I was not, but I am referring to texts I received from my ex-husband.
HJ: Have you had it reported by your husband that Richard had passed faeces? SH: Yes, but he was concerned Richard’s abdomen was still very distended. The junior doctor asked John whether his tummy was normally like that and John told him, no, it wasn’t.
Mr. Hugh-Jones retired from the ring.

Mrs. Handley then had a bout of verbal fencing with counsel for United Response, the housing and care provider:
UR: Would welcome your thoughts on bowel movements in 2011 and 2012. Did you notice a difference in Richard’s willingness to go to the toilet? SH: No, not at all, when he needed to go when he was at mine he was always very happy to have me in the bathroom with him.
UR: He’s been described as being able to go to the toilet independently. SH: I wouldn’t agree with that, especially for bowel movements, he wasn’t capable of cleaning himself up.
UR: Was he able to deal with the bowel movement itself but not clear up afterwards? SH: In essence yes, except in order to have a bowel movement, he needed his mind taken off what was happening so he’d relax and let go – which was the point of the games and physio.
UR: Was that something you discussed with staff at all? SH: Yes, when we had the meeting with Suzan Collins and Clara Paolantonio @unitedresponse.
UR: Was that later discussed with staff in 2012? SH: No, I had no reason to believe it needed to be.

I remembered Sara Ryan at her son’s inquest. Counsel clearly knew he was on dodgy ground insinuating that it was Sara’s, not the staff’s, job to keep Connor safe in the Unit: “I preface this is not a criticism but want to make sure what you say about it, do you accept that during Dr J’s admission of Connor and your call with the Occupational Therapist you… didn’t mention the need to observe Connor in the bath?”
Even in compressed tweet-form, Dr. Ryan’s breathtaken outrage and pain came screaming through: “Yes, but can I add it didn’t occur I’d need to raise with specialist staff? This was a unit that cost £3,500 a week to keep Connor in it!…It would have been a bit like asking a school teacher who took one of our kids on a school trip not to let them loose on a motorway.”

Sheila Handley, I thought, has definitely learned from watching Sara Ryan’s ordeals at the Connor’s inquest and at the GMC tribunal considering Connor’s psychiatrist’s fitness to practise. She’s learned not to get discombobulated by the can-you-just turn-to-page-x trick; she’s learned the value of the “Yes, but…” response; she’s learned how to contradict, politely, statements she considers inaccurate; and she’s learned how to shovel attempted slopey-shouldered offloads of responsibility, right back to where they belong.

Two things leap out at me from this. One is just how much of a nonsense the concept of a ‘non-adversarial’ inquest is. Families want answers, but public bodies want to swerve liability and manage reputation. If their hired gun chooses to take the route of blaming the person’s family, (usually via motherblame, it has to be said) the organisation doesn’t care, as long as the ploy works out for it. In consequence, family witnesses like Sheila Handley have in effect to quasi-professionalise themselves through a form of (self)-training, in order not to be annihilated by the process/ordeal.

The second is that while the organisations are busy fending off responsibility, they will have less attention to devote to improvements for similar patients who may now be at risk. Circling the wagons, not reflecting and changing. It is more than sad, it is sickening to think that the most salient ‘learning from deaths’ to come out of Connor’s drowning may be, not the lesson that Sara Ryan hoped the NHS would learn: How To Provide Good Healthcare To Learning-Disabled People And Avoid Them Dying Prematurely, not the lesson that Mr. Coroner Salter wanted Southern to learn: How Properly To Care For Patients With Epilepsy, but this lesson for other bereaved families: Learn How To Outflank A Barrister At Your Child’s Inquest.
­

The Death Decisions.

27 Wed Sep 2017

Posted by Kara Chrome in Uncategorized

≈ Leave a comment

Tags

family, preventable deaths, true stories

Got to the point in Justice For Laughing Boy where the family are being asked if they ‘would…prefer burial or cremation for Connor’.

‘He.  Can’t.  Be.  Incinerated.’

I’ve never been involved in making arrangements after someone has died an orderly, expected death. When they’ve gone out, full of years and without too much pain, having made their wishes known.  I don’t know what that’s like, although I’m sure it’s still intensely distressing.  What I do know, is that after an unexpected and violent death, being asked ‘burial or cremation?’ is like being whacked on the ear with a lump hammer.  Dizzying, numbing, nauseating, causing black spots in front of the eyes.

When the children’s Papa and I were making our wills, the solicitor suggested that we put in them which of the two options we would prefer.

‘It helps relatives afterwards,” he said.

I hope so.  But – heads-up, E and G – you get asked anyway.  Not that it was a hard decision for your Grandad’s funeral.

“Burial or cremation?”  All our previous family funerals had ended at the crem, where the coffins of my grandparents and aunt had disappeared, three-odd decades previously, behind brocade curtains.

“Burial.”

We couldn’t possibly sit through a cremation. It would be like colluding in finishing off the job his illness started.

The Irresponsible Clinician.

09 Wed Aug 2017

Posted by Kara Chrome in Uncategorized

≈ 6 Comments

Tags

#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.

GMC Murphy notification

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

GMC Murphy 2

GMC Murphy 3

GMC Murphy 4

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 presence of epilepsy, in the face of the inquest findings, although she apparently continues to claim that its management was not her responsibility. Oddly, she also still appears to contend that she obtained a history of Connor’s epilepsy that included whether seizures made him tired and need to sleep. If she had done so, why did she then ignore that he was drowsy at unlikely moments?

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, in order to improve his client’s chances of appearing the reverse.  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 patient’s 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, disrespectful and cruel’; in short, thoroughly unsuited to being a consultant psychiatrist.

An irresponsible clinician.

Brief and Briefer : Justice4LB@GMC.

07 Mon Aug 2017

Posted by Kara Chrome in Uncategorized

≈ Leave a comment

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 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.

LB: Another Day…In Court.

10 Wed May 2017

Posted by Kara Chrome in Uncategorized

≈ 1 Comment

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.

09 Thu Jun 2016

Posted by Kara Chrome in Uncategorized

≈ 1 Comment

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.

A cooked puff pastry pie on a plate with the words humble pie carved out in pastry on the top

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

Slovestatement1large

Slovestatement2large

*****

I.Can’t.Even.

04 Wed May 2016

Posted by Kara Chrome in Uncategorized

≈ Leave a comment

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 ansafone response.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.

– – – – –

Reassurance.

19 Tue Apr 2016

Posted by Kara Chrome in Uncategorized

≈ Leave a comment

Tags

#107days, #justiceforLB, #justiceforNico, #Mazars, preventable deaths, Sloven Health

News today that the Hampshire All Party Parliamentary Group is to ‘quiz’ Southern Health Chief Executive Katrina Percy.

The piece is not very clear on exactly what is expected to happen. Initially we are told that Ms Percy will be ‘scrutinised’, which sounds promising, and would be a novel experience for the Trust CEO, who is accustomed to being deferred to and lauded. But then it appears that Ms. Percy will be ‘addressing the meeting’, which sounds, depressingly, much more in keeping with her preferred style. On the other hand, local MP Suella Fernandes is expecting some ‘frank questions’ to be put. But there again, the said Member for Fareham is only wanting ‘reassurance’.

Ms. Fernandes, I can tell you now, you will get reassurance by the syrupy bucketload. Reassurance is a Sloven speciality, to be poured generously over concerns until they disappear under the sticky golden tide of sugary sweetness. And the recipe for this elixir of reassurance seems to be one part sparkly mendacity to two parts emollient obfuscation, spun into impenetrable thickness in an expensive PR machine.

The New Forest East MP, Julian Lewis, however, has shown himself in the past highly capable of subjecting Sloven spin to truly rigorous, data-based scrutiny (thank-you, @59kemppaul, for the heads-up). I hope Mr. Lewis is able to attend the meeting and give Ms Percy a thorough in-person grilling. Because while a few may be content to swallow syrup of reassurance, what everybody else wants is knowledge: knowledge that crunches like an crisp apple with the sharply acid taste of factual truth.

← Older posts

Subscribe

  • Entries (RSS)
  • Comments (RSS)

Archives

  • Aug 2022
  • May 2022
  • Dec 2021
  • Nov 2021
  • Mar 2021
  • Oct 2020
  • Mar 2020
  • Nov 2019
  • Jun 2019
  • May 2019
  • Apr 2019
  • Mar 2019
  • Feb 2019
  • Dec 2018
  • Aug 2018
  • Jun 2018
  • Apr 2018
  • Feb 2018
  • Jan 2018
  • Dec 2017
  • Oct 2017
  • Sep 2017
  • Aug 2017
  • Jul 2017
  • Jun 2017
  • May 2017
  • Mar 2017
  • Nov 2016
  • Oct 2016
  • Sep 2016
  • Aug 2016
  • Jun 2016
  • May 2016
  • Apr 2016
  • Mar 2016
  • Dec 2015
  • Oct 2015
  • Sep 2015
  • Aug 2015
  • Jul 2015
  • Jun 2015
  • May 2015
  • Apr 2015
  • Mar 2015
  • Feb 2015
  • Jan 2015
  • Dec 2014
  • Nov 2014
  • Oct 2014
  • Sep 2014
  • Aug 2014
  • Jul 2014
  • Jun 2014
  • May 2014
  • Apr 2014
  • Mar 2014

Categories

  • Uncategorized

Meta

  • Register
  • Log in

Blog at WordPress.com.

Privacy & Cookies: This site uses cookies. By continuing to use this website, you agree to their use.
To find out more, including how to control cookies, see here: Cookie Policy
  • Follow Following
    • Who By Fire
    • Join 52 other followers
    • Already have a WordPress.com account? Log in now.
    • Who By Fire
    • Customise
    • Follow Following
    • Sign up
    • Log in
    • Report this content
    • View site in Reader
    • Manage subscriptions
    • Collapse this bar
 

Loading Comments...