Doctor who admits failings now works in Ireland

"A psychiatrist who admitted a series of failings over the death of a teenager with autism is understood to be still working in Ireland."

"Dr Valerie Murphy was the lead clinician in charge of Connor Sparrowhawk’s care when the 18-year-old had an epileptic seizure and drowned in a bath."

"The clinician who was in charge of his care has admitted 28 failings..."

"These included failing to carry out any risk assessments and failing to meet Connor’s clinical needs relating to his epilepsy and the bathroom. They also included failing to follow National Institute for Health and Care Excellence guidelines."

"Connor died in the bath at Slade House, Oxfordshire, in July 2013..."

"Connor’s death led to the discovery that Southern Health had failed to properly investigate the deaths of more than 1,000 patients with learning disabilities or mental health problems."

"The trust has accepted responsibility for Connor’s death and faces prosecution by the Health and Safety Executive."

https://www.autismeye.com/connor-sparrowhawk-death/#.WZw2ij_4KPc.facebook

Connor Sparrowhawk

Tribunal starts today about Connor

 

Sara Ryan and Connor's family have informed the public that the charges against Dr Murphy will be explored at the General Medical Council tribunal starting today for two weeks. [#JusticeforLB]

"The tribunal will enquire into the allegation that, between January 2012 and June 2014, Dr Murphy was employed by the Southern Health NHS Foundation Trust. It is alleged that, during this employment, the risk assessments carried out by Dr Murphy, in relation to Patient A, were inadequate and she failed to adequately and appropriately gain consent from Patient A and/or his parents for the care and treatment provided."

"It is also alleged that, on 9 April 2013, Dr Murphy prescribed risperidone to Patient A but failed to explain the benefits, risks and side effects of the medication to the patient; indicate whether lorazepam had been used and/or whether it was effective and make a diagnostic formulation for the administration of risperidone."

"It is further alleged that Dr Murphy`s completion of mental capacity assessment forms for Patient A on 16 April 2013 and 21 May 2013 were inadequate."

----------------

See A pre-tribunal Sunday in August

Charity will have largest facility in Europe

This is very bad news for young people and their families.

"A charity is set to build Europe`s largest mental health facility for young people in Northampton."

"St Andrew`s the UK`s leading charity providing specialist NHS care, has received planning approval to construct a new residential building for young people with mental illness, autism and learning difficulties in Northampton."

"Designed by P+HS Architects, the new building on Cliftonville Road, which will cost £45 million, will bring together adolescent services at St Andrew`s on one site and will be the largest facility of its kind in Europe."

"It will provide care to young people from across the United Kingdom, and alongside 110 residential beds, it will include a school, sports and therapy areas, and a number of landscaped courtyards."

http://www.northampton-news-hp.co.uk/europe-8217-s-largest-mental-health-facility/story-22905825-detail/story.html


See Finola Moss`s blog: New Gold Rush: forced residential care

Also see Sara Ryan`s blog: The mystery of Loring Hall and the CQC*

*CQC Care Quality Commission

Southern Health NHS Foundation Trust to be prosecuted

"An NHS trust is to be prosecuted over the drowning of an 18-year-old patient at one of its facilities, the BBC has learned."

"Connor Sparrowhawk suffered an epileptic fit while in a bath at Slade House in Oxford in July 2013."

"Southern Health NHS Foundation Trust eventually admitted responsibility and offered his family compensation."

"The Health and Safety Executive (HSE) told the BBC it will now prosecute the trust."

 

"Following the announcement, Mr Sparrowhawk's mother Sara Ryan said: `I still feel really sad about it`."

"`I just feel we've been put through the mill. We have been treated appallingly and a young man should be doing whatever he would be doing right now`."

"`He should never have died`..."

---------------

"The HSE said it was prosecuting the trust `under Section 3 of the Health and Safety at Work etc Act 1974 following its investigation into the death of a patient under its care`."

"A jury-led inquest in October 2015 found that `failings` by trust staff contributed to Connor's death."

"The trust's boss Katrina Percy resigned in October amid public pressure."

http://www.bbc.co.uk/news/uk-england-oxfordshire-39859898

Governor, Southern Health NHS Trust, under investigation

Peter Bell, Jade Taylor and Richard West

 

17 May 2016 Daily Echo

"Rebel governors who have a say on how Southern Health NHS Foundation Trust is run have broken ranks from the leadership by resurrecting a crunch meeting to demand improvements at the organisation... "

"And in a remarkable twist they raised the money needed to hire the hall through online crowdfunding..."

"Just one governor, Peter Bell, had arrived at the splinter meeting by the start time of 11.45am, with three more following. Mr Bell is proposing a vote of no confidence in the leadership."

"As previously reported, the trust announced it was postponing the extraordinary council of governors meeting after organisers say the decisions made would not be legal."

"The trust’s new chair Tim Smart had also come under fire as he was due to exclude the press and the public for part of that meeting."

"Southern Health has been condemned after failing to protect patients and investigate the deaths of hundreds of people in its care."

http://www.dailyecho.co.uk/News/14497597.UPDATE__Health_trust_thrown_into_chaos_after_bizarre_split_by_rebel_bosses/

Then this: Mydaftlife July 2016

 

"Got home to find out one of the rebel governors, Peter Bell, is under formal investigation by Sloven. Yep. Sloven are formally investigating the actions of a (rare) governor."

"Sloven who:
initially said LB died of natural causes and all due process was followed.
tried to stop the publication of the first Verita investigation which found LB’s death was preventable.
spent nearly £300,000 on legal expenses at LB’s inquest to try to avoid accountability.
spent nearly £50,000 to try to sink the Mazars review into their death reporting.
have been found to be failing by numerous coroners over the past five years
etc, etc, etc…"
"Blimey. A formal investigation…"

" `Seriously derogatory remarks’…. Not sure where, in the guvs’ code of practice, it states ‘thou shalt not say owt negative against the hallowed trust’..."

"LB died. He died. Without any accountability. But the investigation into the actions of a governor is racing on. Interviews, evidence collecting and all. By an organisation who failed to investigate 100s of unexpected deaths in their care. I almost think I’ll wake up in a mo. Surely this can’t be happening in full view of NHS Improvement, NHS England, the CQC and Jeremy Hunt?..."

https://mydaftlife.com/2016/07/24/when-trusts-go-bad/

Tim Smart finds no evidence of negligence



Katrina Percy


"It's three years ago today that a young man drowned in a bath at a care home in Oxford, prompting one of the UK's biggest ever inquiries into the treatment of vulnerable patients."

"Connor Sparrowhawk's death was a personal tragedy, but also a wake up call about failures in the care system..."

"Southern Health have declined numerous requests for interview. In a statement last week, the Trust's Interim Chairman Tim Smart said:"

"I am satisfied that whilst the Board should have acted in a more united way, I have found no evidence of negligence or incompetence of any individual Board member..."

"I can confirm that Katrina Percy will continue in this role ( as Chief Executive). However, until now she has been too operationally focused in her role."

http://www.itv.com/news/meridian/update/2016-07-04/remembering-connor-campaigners-anger-on-third-anniversary-of-teenagers-death/

Alicia Wood, Co-Founder of Learning Disability England said:

"I am appalled that Katrina Percy has kept her job despite continual and evidenced failings over a sustained period. The lack of care for people with learning disability and mental ill health due to poor leadership has been established and those in leadership positions within the trust should have resigned a long time ago out of respect to those who have died, suffered and been neglected by the trust.

http://peoplefirstengland.org.uk/connor-sparrowhawk/learning-disability-englands-response-to-tim-smart/

See also http://dataforlb.blogspot.co.uk/2016/07/the-return-of-repressed.html

Care in crisis

 

 

"A Westminster Hall debate on the Governance of Southern Health NHS Foundation Trust has been scheduled for Wednesday 8 June 2016 at 2.30 pm. It will be led by Suella Fernandes."
 

http://researchbriefings.parliament.uk/ResearchBriefing/Summary/CDP-2016-0111#fullreport

Vexatious phone call to Sara Ryan

From Justice for LB:

 

"I’ve spent about an hour trying to write a blog post but keep deleting the words. Today Sara shared the audio message below which she picked up from her work answerphone."

"Good morning, hello, hi, this is a message for Dr Sara Ryan, um I’ve been seeing on the media about your son, your poor son who died in the care of Southern Health. I work for Southern Health and I feel awful that you lost him, I’m so sorry that you have done, it’s tragic, and, I hope you find some closure after the report, the issue of the GM… urgh CQC report today, but I do think you are being very vindictive. I think you are a vindictive cow."

"On TV all the time, ummm, slating the NHS Southern Health. With your intelligent background, you know, as much as much as anyone else knows, that Southern Health only took over those units in Oxfordshire recent, 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 [inaudible] and you want some attention, but you are vindictive and you are unpleasant, and you are a nasty cow." 

9.33am Friday April 29th 

 http://justiceforlb.org/a-culture-of-candour-justiceforlb/

Dr Sara Ryan has recently passed on leaked documents to the police showing that Southern Health NHS Trust was already aware of the dangers to patients 10 months before her son died in their care.

See also http://www.bbc.co.uk/programmes/p03sl96n?ns_mchannel=social

Southern Health NHS Trust was not safe

"An NHS trust knew of failings at a care unit 10 months before a teenager drowned in a bath there, the BBC has learned."

"A leaked 2012 review found staff did not feel Slade House, Oxford, was safe and that it was dirty and difficult to track the care of patients at the unit."

"Connor Sparrowhawk, 18, died at the site in July 2013."

"Southern Health NHS Foundation Trust said a post-review plan had not been completed before his death."

 

 

"Dr Sara Ryan, his mother, said she would be asking police to open an investigation."

"She said the leaked documents were the `missing piece` for a corporate manslaughter charge, and described seeing the 2012 report as `devastating`."

" `Numerous things were wrong that were clearly important failings. To think that was known about… is awful, shocking, and harrowing,` she said."

http://www.bbc.co.uk/news/uk-england-oxfordshire-36141808

100 days after the Mazars report nothing has happened

"Three years ago, aged 18, Connor drowned in a bath at Slade House, a residential unit run by Southern Health, an NHS foundation trust. His parents had brought him there a few months before, after he became aggressive and violent, and they found themselves unable to cope. `It felt as if we were buying a bit of time for everyone, including Connor,` Richard says. `These guys were professionals, Connor would get some support. We thought it was a terrible thing to have to do, but it was fair. Within a few days we thought the place wasn’t very good. But we never, ever thought he wouldn’t come out.` "

"In October last year, a jury delivered a damning verdict, that serious failings and neglect had contributed to Connor’s death. Two months later, an astonishing report by audit firm Mazars, commissioned by NHS England in 2014 at the request of Connor’s family, found that Southern Health had failed to properly investigate the deaths of more than 700 people with learning disabilities or mental health problems, over a four-year period, from 2011 to 2015."

"In a statement to the Commons on 10 December last year, health secretary Jeremy Hunt said that the Mazars report had raised serious concerns about Southern Health, which cares for about 45,000 people in Hampshire, Dorset, Wiltshire, Oxfordshire and Buckinghamshire..."

"But 100 days on from the Mazars report, [Sara Ryan] is beginning to think she was naive. `We thought the report would become a national priority for action. And nothing has happened.` She is looking at the possibility of bringing a class action, with other families, against Southern Health, one of the largest mental health and learning disability trusts in England..."

Katrina Percy

 

"In December, Sara called for the chief executive of Southern Health, Katrina Percy, to resign. The trust acknowledged the failings documented in the Mazars report: `We fully accept that our processes for reporting and investigating deaths of people with learning disabilities and mental health needs were not always as good as they should have been.` But it also defended its record, stating that, `National data on mortality rates confirms that the Trust is not an outlier and it`s rate of investigations is in line with that of other NHS organisations`. (`As if that makes it all right!` Sara says.)"

"Percy made a public apology: `Connor needed our support. We did not keep him safe and his death was preventable.` She added that many changes had been made since Connor died. Percy is still in post."

"For Sara, the Mazars report crystallised what she had always suspected. `It’s a eugenics thing,` she says. `There’s no value attached to their lives.` "

Read more http://www.theguardian.com/society/2016/apr/02/never-thought-he-wouldnt-come-home-why-son-connor-sparrowhawk-die?CMP=share_btn_tw

The erosion of accountability in the NHS

"The #JusticeforLB movement has succeeded in exposing the most disturbing and penurious facts about the British states treatment of learning disabled people since the Winterbourne Inquiry (which detailed the criminal abuse by staff of patients at a privately owned care facility called Winterbourne View Hospital, near Bristol, but was only exposed by the work of undercover journalism supported by the BBC’s Panorama team). "

"Since Connor’s death, many have come forward to speak about ongoing failures in care for learning disabled people, about neglect, about their struggles to get answers about the deaths of loved ones, and about their fears for the future in the face of seemingly permanent reductions in funding for adult social care. In the context of permanent austerity, Connor’s death raises fundamental questions about the future of welfare itself. "

"Indeed, it is imperative that we understand #JusticeforLB’s struggle for accountability within the context of what Youssef El-Gingihy calls the `virtually impenetrable` Health & Social Care Act 2012, which came into law three months before Connor’s death. One of the first casualties of the Health and Social Care Act was accountability itself - as Jacky Davies, John Lister and David Wrigley note in their important account of the systematic demolition of the NHS, NHS for Sale: Myths, Lies and Deception. Questions about the impact of NHS reforms on accountability were raised by many before the Act came into law; see for example Accountability in the NHS: Implications of the government’s health reform programme and Lords warn on ministerial accountability in NHS reforms."

"While we know why Connor died (he died of neglect), to have his death accounted for has proven more challenging. This is due in no small part to the baffling complexity of what we used to call ‘the National Health Service’ (NHS). In effect, the NHS no longer exists, or at least not in a form those who created it would recognize..."

"Today, the closest thing we have to central governance, and national level accountability, within the NHS is `a body` called NHS England, which receives the bulk of tax-payers funding to pay for the services we receive. NHS England is primarily a commissioning body, however, the bulk of actual commissioning work is devolved to local ‘Clinical Commissioning Groups’ (made up of a select few doctors and nurses, ‘health managers’ and a significant number of private health company representatives and shareholders) who commission services from a range of public and private ‘service providers’."

"These changes in the government of the National Health Service were made, the public was told, in order to `liberate` hospitals, GPs and local authorities. As of 2012, this tangle of ‘NHS bodies’ would decide what kinds and levels of provision to make to the public."

"Much of the groundwork had been laid by pro-market ministers under Tony Blair’s government, who started encouraging NHS hospitals to become business-like ‘Foundation Trusts’ – but Cameron’s 2012 Act seriously ramped up the shift from central, state accountability, to ‘market’ accountability, leaving local NHS managers no other choices."

"In the case of Connor Sparrowhawk, the ‘liberated services’ which had been ‘commissioned’ to care for him were provided by an NHS Foundation Trust called Southern Health, who are one of England’s largest providers of ‘community health, specialist mental health and learning disability services’. Mazars concluded that those in charge of overseeing the delivery of Southern Health services had catastrophically failed. In particular they noted that a ‘failure to bring about sustained improvement in the identification of unexpected death and in the quality and timeliness of reports into those deaths is `a failure of leadership and of governance`."

"What are the consequences of this failure? Who can be held to account in a context where the government has devolved its `constitutional responsibility` to provide NHS services? Where does legal and political responsibility lie? With those whose neglect contributed to Connor’s death? With Southern Health? With the CCG who commissioned their services? With NHS England? With the Secretary of State for Health? If all of these ‘bodies’ are in some part accountable, who can hold them to account, what are the systems for accounting?"

The hollow rituals of apology without accountability
"On December 10th 2015, the leaked Mazars findings provoked the tabling of an ‘urgent question’ to the Health Sectary Jeremy Hunt in the House of Commons. Hunt made a public apology to Sara Ryan and her family. Hunt thanked the #JusticeforLB campaign, and suggested he was grateful for their exposure of the failures at Southern Health."

"However, in his co-authored 2005 book, DIRECT DEMOCRACY: An Agenda for a New Model Party, Hunt not only put forward a case for the privatisation of the NHS, but specifically argued for an end to government accountability for the welfare state. The introduction stated, `what is needed is not the accountability of services to central government – precisely the error of the Attlee settlement whose failed systems we still inhabit.`"

"Attlee was the Labour Prime-Minister (1945 to 1951) who oversaw the development of the post-war welfare state. His Health Minister, Aneurin Bevan, created the National Health Service (NHS) in 1948. Hunt’s political ambition, to rid the government, and specially the Department of Health, for accountability for failures in care, is precisely what has come to pass, through the establishment of NHS England, and chaotic and ill-prepared local Clinical Commissioning Groups. Decentralised ‘accountability’, said Hunt's book, ‘must be direct, democratic and local’. In actuality Hunt’s ‘devolved’ accountability equates to market-based accountability, which exercises authority through obfuscation - strategies which seems to centre on tiring out those who attempt to question and challenge."

"To put it more plainly, permanent reductions in public services necessitates the erosion of structures of accountability. "


The bones of hope
 "The #JusticeforLB campaign has exposed the extent to which NHS ‘reforms’ have undermined systems of public accountability for publically funded services. This has been no small undertaking, but has involved the harnessing of an arsenal of digital and off-line activist strategies: twitter, blogging, vimeo, the #LBBill, the Justice Quilt, the Justice Shed, films, art exhibitions, picnics and flags. This is a movement grounded in grief and love, but moved, agitated, kept alive, by the promise of justice for people with learning disabilities, and the possibility of a different welfare future."

https://www.opendemocracy.net/ournhs/imogen-tyler/connor-sparrowhawk-erosion-of-accountability-in-nhs?utm_source=Sign-Up.to&utm_medium=email&utm_campaign=32163-141431-North+of+England#.VrNQw5J1cQ0.twitter

Has the LB campaign produced a `cultural turning point`?

Not according to Rob Greig, chief executive of the National Development Team for Inclusion:

"The Justice for LB campaign is widely, and rightly, viewed as one of the most successful examples of the mobilisation of public opinion to challenge service failure."

"For those not familiar with it, Connor Sparrowhawk, a young man with learning disabilities, died while under the care of Southern Health NHS Foundation Trust in July 2013. Given the trust’s failure to accept responsibility, Connor’s family and friends launched the Justice for LB campaign (Laughing Boy, ‘LB’, was Connor’s nickname)".

"The trust initially said Connor died of ‘natural causes’ but an independent investigation found his death could have been prevented. Last year, an inquest jury found that neglect contributed to his death."

‘Failure of leadership’

"Before Christmas, there was a sense that this campaign was leading to real change. Most notably, the findings were revealed from an NHS England-commissioned report (the Mazars review) into Southern Health’s handling of patient deaths."

"The report described how the trust had, among other things, failed to investigate hundred of unexpected deaths of people with learning disabilities or mental health conditions. It blamed a `failure of leadership` and warned investigators had `little confidence` the trust fully recognised the need to improve."

"Strong words were said by people in authority. Health secretary Jeremy Hunt was `profoundly shocked` by the findings. Simon Stevens, NHS England’s chief executive, spoke of the health service being at a `cultural turning point` at which it must change the way it responds to families."

Lack of changes

"However, since Christmas, far less has been said. It is also hard to identify any significant change to emerge from the litany of criticism that followed the Mazars report. What has happened to permit the silence that now surrounds this scandal?"

Read more http://www.communitycare.co.uk/2016/02/16/learning-disability-scandal-swept-carpet/

See also http://alicemooreuk.blogspot.co.uk/2016/01/connors-parents-should-take-comfort.html

Connor`s parents should take comfort

A report was "commissioned by NHS England (South) following the death of Connor Sparrowhawk in July 2013 in a unit in Oxford run by Southern Health NHS Foundation Trust."

Following another Southern Health Board meeting, Mark Neary is angry and who could blame him ?

"Mencap have a representative on the Southern Health Board of Governors. Her name is Liz Hall. It should be good. The `Voice of learning disability` has an input and could offer an important insight in addressing the zillions of issues raised by the Mazers Report, Monitor, the CQC, Several Coroners, the Health Secretary, NHS England, etc etc..."

"Here is Liz Hall’s minuted contribution to the latest Southern Health Board Meeting:"

"This sad affair with Connor Sparrowhawk has triggered off, at last, the enormous training issues that are still prevalent in society, including general hospitals, education establishments, training of the public, schools, the police force, etc. Shall I go on? However, it’s an ill wind that blows nobody any good and indeed one feels that perhaps Connor’s parents can take some comfort from this tragedy that has at last shown up the enormous ‘gap’ in training that has been shown up. It’s not only in Hampshire and Oxfordshire – sadly it’s still there all over England and in many other countries in the world. So here is our opportunity to begin some very exciting training of the public, police forces, nurses, doctors, school teachers, social workers and above all hospital staff on how to communicate with those with learning disabilities and involve their families more effectively in their care and life styles which we as a health authority, along with the rest of England begin to understand how one communicates, protects, and includes more of us all in their lives. We have achieved it better with other groups or so called disabled people so let’s begin to engage in training – we could make some money out of it too."
 
https://markneary1dotcom1.wordpress.com/2016/01/26/the-ill-wind-of-1000-learning-disabled-deaths/

See also http://alicemooreuk.blogspot.co.uk/2016/01/the-mazars-report-and-beyond.html

The Mazars report and beyond

A report was "commissioned by NHS England (South) following the death of Connor Sparrowhawk in July 2013 in a unit in Oxford run by Southern Health NHS Foundation Trust."

"The report now recommends further action... in particular that its findings should be shared across England to ensure that deaths are investigated properly..."

https://www.england.nhs.uk/tag/mental-health/

 

"Jeremy Hunt is facing calls for a nationwide inquiry into the deaths of highly vulnerable patients in NHS care after it emerged that just one in seven such fatalities in hospitals in England have been investigated. "

"Data released to the Guardian under freedom of information laws shows that hospitals in England have investigated just 209 of 1,436 deaths of inpatients with learning disabilities since 2011..."

"The data appears to show that recently exposed failings at the Southern Health NHS trust in the south of England are widespread. At that trust, just four of 93 unexpected deaths among people with a learning disability were looked into. Trusts are meant to look into and learn from unexpected deaths under tougher NHS-wide patient safety rules introduced since the Mid Staffs scandal to reduce the risk of mistakes being repeated..."

"Jeremy Hunt, the health secretary, last week criticised the lack of leadership at Southern Health for failing to investigate unexplained deaths, but he will now face pressure for a wider inquiry..."

"NHS England said it recently wrote to every trust asking them to review and report on avoidable mortality rates. "This places England as the first ever country to monitor the extent of avoidable deaths."

"A government-funded inquiry reported in 2013 that an estimated 1,238 children and adults with learning disabilities die every year in England as a result of getting poor care from the NHS."

http://guardian.newspaperdirect.com/epaper/viewer.aspx

From Justice for LB

It is now 16 days since NHS England published the Mazars report... Despite the horror that it contains, the responses by the Secretary of State and by the triumvirate that is NHS England, CQC and Monitor, are unanimous in their feebleness and lack of urgency.  

Southern Health are holding two extraordinary meetings in the next ten days. The first is of their Governors, which takes place in Southampton on Tuesday 5 January from 10-12noon... The second meeting is of the Board, and that takes place in Southampton on Monday 11 January from 8.30-9.30am... Members of the public can ask questions at both meetings, you can submit them in advance if you wish, but there is no requirement to do so.

It is almost like Southern Health don’t want people to know about the meetings. They’ve not advertised them on their news pages or via any of their social media platforms, despite being big fans of viral leadership. We are hoping as many JusticeforLB’ers as possible will attend both meetings...

Read more http://justiceforlb.org/extraordinary-times-mazars-southernhealth/

See also  https://mydaftlife.wordpress.com/2015/12/29/trusts-and-scandal/

Will Katrina Percy resign ?

Katrina Percy, Chief Executive of Southern Health NHS Foundation Trust was celebrated as one of the most inspirational women in healthcare in the Health Service Journal...

"In November 2012 Katrina beat tough competition from other NHS leaders from across the country to win ‘Chief Executive of the Year’. "

http://www.southernhealth.nhs.uk/news/archive/2013/hsjwomen/

Recently Ms Percy`s climb to stardom has taken a downturn. There have been an avalanche of protests since the Mazars report was leaked to the BBC about the 1000 and more unexplained deaths in the care of Southern Health NHS Trust.

From ITV.com

Statement from Katrina Percy, Chief Executive of Southern Health NHS Foundation Trust:

Does Ms Percy feel that, considering the comments of Jeremy Hunt - "The Government is profoundly shocked by the findings of the report which are totally unacceptable" - she should resign as Chief Executive?

Do other senior members of the Trust feel they should 'step down' over the comments by Mr Hunt of "a lack of leadership"?

"It is my job and that of the Board to continue to lead on the comprehensive programme of improvements which we have been making over the last 18 months. We owe it to the people we support to make these improvements and it is this that we are focussed on."

_Does Ms Percy and the Trust feel they have let down the most vulnerable members of our society?_

"We apologise to anybody who feels let down by any aspect of our service. The safety and welfare of the people we support is of utmost importance and we take seriously any part of service which has not met the high standards we expect. We have accepted that our processes have not always been as good as they need to be and are committed to improving them."

What does she say to the families of the 1,454 people who have died unexpectedly between April 2011 and March 2015?

"I say that we have already made significant improvements to the way we report and investigate unexpected deaths, and are working extremely hard to encourage other organisations to do the same. "

The full report - not the leaked one - will be released before Christmas...

http://www.itv.com/news/meridian/update/2015-12-10/statement-from-chief-exec-of-southern-health-nhs-foundation-trust/

Some families are speaking out:

What a difference a day makes

David-Goliath-Katrina

GMP: genetically modified percy

Deaths were not properly investigated

"The NHS has failed to investigate the unexpected deaths of more than 1,000 people since 2011, according to a report obtained by BBC News."

"It blames a "failure of leadership" at Southern Health NHS Foundation Trust."

"It says the deaths of mental health and learning-disability patients were not properly examined..."

"The trust covers Hampshire, Dorset, Wiltshire, Oxfordshire and Buckinghamshire, providing services to about 45,000 people..."

"The culture of Southern Health, which has been led by Katrina Percy since it was created in 2011, `results in lost learning, a lack of transparency when care problems occur, as well as lack of assurance to families that a death was not avoidable and has been properly investigated,` the report says."

http://www.bbc.co.uk/news/health-35051845?SThisFB

Inequality of arms

"Through their campaign, Justice for LB, Connor's family managed to fundraise £26,000: enough to pay a solicitor, but not their two barristers, who worked pro bono. Sara believes that their lawyers had a big impact on how the inquest, which finally concluded last week, was conducted..."

"For example: the coroner was initially undecided about whether a jury should be present at the final hearing. Though an independent report found that Connor's death was preventable and Slade House was subsequently shut down after failing an inspection, Sara says that at the pre-inquest review the Trust's lawyers still argued that Connor died of natural causes and that he had not actually been detained in the unit, so a jury would be unnecessary. "

 

"The first argument – that a death by drowning was not unnatural – was immediately dismissed by the coroner. But the second was less clear cut. "The argument about whether or not Connor had been detained was relentless," says Sara. "It probably took our barrister about 20 minutes of careful arguing, holding up case law and all the rest of it, for the coroner to eventually accept that he was. And we would never have been able to do it on our own." A jury inquest was granted. "

"For Mr Dias, this kind of legal wrangling is to be expected at a state death inquest. He says that families initially come to him relieved that their relative's death will finally be investigated. "I have to advise them, time and again, you must understand that this will be terribly, terribly difficult," he says. "Because when something like that happens, rather than throwing open its doors to expose systemic wrongdoing and individual and collective failures, the state closes the doors and you have to bash them open."

http://www.vice.com/en_uk/read/uk-inquest-system-needs-fixing-720

See also
http://alicemooreuk.blogspot.co.uk/2015/10/justice-for-lb-unanimous-finding-by-jury.html

Justice for LB: Unanimous finding by jury

"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 ."

"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."

"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 . Lack of clinical leadership on the STATT unit."

https://whobyf1re.wordpress.com/2015/10/16/lbs-inquest-day-10-afternoon-the-verdict/comment-page-1/#comment-276


Ned Ludd gives his condolences to the family of Connor Sparrowhawk and asks some questions:

"How was a death after an epileptic fit in the bath accepted by anyone initially as from 'natural causes'?"
"Where was (and is) CQC in this tragedy - and more importantly why weren't they there to prevent it (Too busy to have carried out an inspection)?"
"Why is it that the only real check on the quality of care is still the family?"

http://nedluddcarer.blogspot.co.uk/2015/10/condolences-to-family-of-connor.html

Epileptic son left to bathe alone in NHS care unit

"The mother of a vulnerable teenager, who died after suffering a seizure while taking a bath at an NHS assessment unit, has expressed her shock that he was allowed to bathe behind a closed door. Connor Sparrowhawk, 18, who had a learning disability and epilepsy, was found by staff submerged in the bathtub at the unit in Oxfordshire and died later in hospital."

"Speaking at his inquest, Connor’s mother, Sara Ryan, said when he was at home the teenager bathed downstairs with the door open and a family member speaking to him. "I would never have thought of leaving Connor alone in the bathroom for any period of time," she said. "

"But the inquest in Oxford has heard that when Connor took lengthy baths at the Statt (short-term assessment and treatment team) unit at Slade House the door was closed and he was checked only every 15 minutes. "

"Ryan said she had only heard during the inquest that the door was closed and said she would have objected had she known. "

"Asked why she had not mentioned the need to observe Connor in the bath, she said it had not occurred to her to raise it with expert staff. She said it would have been like asking a school teacher taking children on a school trip not to `let them loose on a motorway`."

http://www.theguardian.com/uk-news/2015/oct/13/mother-shocked-epileptic-son-left-to-bathe-alone-in-nhs-care-unit?CMP=share_btn_fb

Read  Dignity, My Arse

Draft LB Bill has been backed by charities

Connor Sparrowhawk

"New rights for people with autism and learning disabilities must be enshrined in law, the mother of an 18-year-old man who died in NHS care has said, ahead of an inquest into his death."

"Connor Sparrowhawk, who was autistic and had epilepsy, was found drowned in a bath at an NHS assessment and treatment unit in Oxfordshire in July 2013, after being left unattended."

"Despite an independent inquiry in 2014 finding that Connor’s death had been preventable, that his epilepsy was not monitored, that there was no adequate supervision for residents when bathing, and that the family were granted no involvement in his care, no one has yet been held accountable..."

"A draft Bill, dubbed the LB Bill, for Connor’s nickname Laughing Boy, has been backed by leading charities and Norman Lamb, the former care minister. Key elements of the Bill were included in a government Green Paper, submitted shortly before the election, that could pave the way for major reform."

"Slade House, the unit where Connor had been living for 107 days before his death, has since been shut down, following a damning report by the Care Quality Commission. Meanwhile the trust which managed it, Southern Health NHS Foundation Trust, is subject to an inquiry into a number of deaths of people with learning disabilities and mental health problems between April 2011 and March 2015."

http://www.independent.co.uk/news/uk/home-news/mother-of-autistic-man-who-drowned-in-nhs-care-wants-new-rights-for-people-with-autism-and-learning-disabilities-10509258.html


See also http://alicemooreuk.blogspot.co.uk/2015/07/the-tale-of-laughing-boy.html