There has been a remarkable level of interest in #justiceforLB. I say remarkable; it’s perhaps more a natural reaction to the even more remarkable fact that Connor Sparrowhawk – a brilliant 18-year-old, son, brother, friend – died a preventable death in the “care” of an institution run by Southern Health that was specifically designed, commissioned and paid to support him and keep him safe.
To get a sense of it all [of course, there is no “sense”; how could there be?] please follow @justiceforLB or the hashtag #justiceforLB.
Today has seen more media activity in specialist press, local news and some interest from national organisations, which is great. It’s nowhere near enough when it comes to what needs to happen and what needs to change, but it’s a start.
And what of Southern Health? In a way, they should be congratulated for their work on the comms and PR side of things. I say this because you may not have thought it was possible for them to be any worse than they already have been at any point throughout this whole situation. The depths they have plumbed have been quite astonishing (quite aside from, y’know, their being responsible for the preventable death of Connor). And yet today they have surpassed even themselves through shameful and callous acts in responding to (or not) public interest in what happened to Connor.
When it couldn’t get any worse, Southern Health somehow found a way. For that, we should congratulate them.
Here I’ll focus on just two elements of Southern Health’s continued exploration of depths to which nobody could ever believe they would sink, though please do share your own thoughts, too (#justiceforLB).
The first element is that the Chief Executive of Southern Health – someone who has won an NHS Leadership award for her “style of leadership that engenders self-motivation among staff” [did someone tell S1 and S3?] – is nowhere to be seen. Sure, her name was attached to Southern Health’s press notice about Connor’s death, but, erm, that’s it. Instead, the person left to represent Southern Health in the media is their Deputy CEO.
Now, I’m no expert on leadership but I’m pretty sure it has something to do with personal accountability and responsibility, and being present when something bad has happened, as well as the good times.
Am I alone in thinking that NHS Leadership Award standing on the mantelpiece at home is looking a bit hollow?
True leadership, despite the fact her son died.
2. Southern Health’s media lines
The second element is the lines that Southern Health have agreed for their press activity.
A media briefing will obviously have been put together for their Deputy CEO. Using their appearance on BBC Oxford News last night and BBC Oxford radio this morning (links here and here respectively, video/audio to follow) let’s explore the key aspects of that briefing.
1. We want to use the findings of this report to improve our services right across the Trust.
The service didn’t meet a single one of the 10 standards inspected by the CQC, 8 weeks after Connor died. You were issued with six enforcement action notices. There were fundamental failures of the most basic nature in the “service” and “care” that was being provided by Southern Health.
Would one of your proclaimed “improvements” be “don’t leave people with epilepsy unsupervised whilst taking a bath?” – the sort of advice any member of the public could give?
And yet the independent investigation found that Southern Health had policies, guidance and pathways in place that should have ensured there were minimum standards of care, but that all of these were simply paperwork, and didn’t translate at all into practice. There were staff actively not engaging with family members. For Connor, there was no epilepsy profile, no medical review, no comprehensive care plan, no epilepsy pathway in operation in Oxford, and epilepsy was not part of Connor’s risk assessment.
You’re fortunate that “improve” is a relative concept, because it’s the only way to accommodate the fact you provided the most fundamentally flawed and inadequate service possible.
2. We’ve asked ourselves “Why was it the CQC found things in our services that we should have found ourselves?”
And what answer did you reach? At what point did it not occur to you to undertake a risk assessment regarding someone with epilepsy taking a bath? When did it seem reasonable for members of your staff to be “thrown off their stride” because a meeting about someone in their “care” was in danger of being person-centred? Who have you found responsible for this failing? How are you not awake every single night thinking about the preventable death you failed to prevent and who else is in danger across all of your services?
3. We experienced delays in our response, in part because of the role of the police.
The police? Someone dies in one of the units you run – where only 4 other people were being held, in a place designed only for 7 people anyway – and you don’t consider changing one thing until the police have looked at the circumstances? Even then, were the police looking at this for 8 weeks, i.e. the time since Connor died and the CQC visited?
4. We can sympathise with Connor’s mum’s position.
5. We’re deeply sorry this has happened.
Are you? Because you’re doing a pretty fucking good job of appearing very insincere in your sorrow.
6. We commissioned an independent investigation.
This was after you’d tried to dismiss Connor’s death as being of “natural causes”, of course.
But, anyway [anyway? Jesus], let’s look at your support of that independent investigation, shall we?
Staff interviewed as part of the investigation inquiry weren’t given relevant paperwork before their interviews. The investigators received substantial additional documents relating to their investigation less than three working days before the report was published, and after the draft report had been sent to you. You insisted the report was redacted to such an extent that it is virtually impossible to determine who did what and when [“we are able to publish a final copy of the fully redacted report. We are of course very pleased about this as it allows a spirit of openness and transparency.” Jokers.]. When Connor’s family appointed an advocate to support them throughout the investigation, you tried to have them removed, citing the most circuitous conflict of interest it’s possible to imagine. You appointed external solicitors. You didn’t commit to making the report public until days before it was due back from the investigators. You published the report at 5.45pm on the day of publication, citing the need for “written permission”, from whom we still do not know.
You may well have commissioned an independent investigation, but you did your damnedest to obstruct the process and publication of that investigation.
7. We want to do anything we can to help Connor’s mum “move on”.
What you mean to say is you want Connor’s mum, and everyone else, to “move on” and leave you alone.
Well, I’m afraid we won’t.