Richard Handley’s inquest concluded yesterday, the coroner found gross failings, missed opportunities and that Richard should not have died. No-one should die of constipation in a civilised society. It’s utterly disgraceful. It makes me so angry and so sad. It’s too early for me to blog about the coroner’s decision or what we might change as a result of what we’ve heard over the last few weeks with any coherence. Last week I summarised the evidence in a post The Life and Death of Richard Handley. I will blog again, just not yet.
There was some excellent news coverage, that managed to capture Richard and not just the awful end of his life. See this from 5 News:
“He had a wonderful sense of humour… he loved tickling people’s toes when they weren’t looking” – Richard Handley’s parents speak beautifully about their son.
Today, an inquest found that a "missed opportunity" for potentially life-saving treatment contributed to his death. pic.twitter.com/nsDIBGPjAr
— 5News (@5_News) February 8, 2018
This on the BBC Richard Handley: Gross failures in constipation death, this on Suffolk Now:
‘Lessons have been learned and yet the deaths continue’ @pingug
‘This process isn’t designed around families’ @LucyWarring
— GeorgeJulian (@GeorgeJulian) February 8, 2018
There was a piece in the Guardian ‘Gross failure’ in man’s care led to death from constipation by Amelia Hill and an opinion piece on the Canary today There’s a reason why a man was allowed to die from constipation. But no one wants to say it by Steve Topple. There has been a lot of coverage on local news too, including BBC Look East (from 6min) including a discussion on BBC Radio Suffolk here and a segment this morning on BBC Breakfast (from 2hrs 21mins). There’s a clip here:
Richard had learning disabilities and was 33 when he died of constipation.
A coroner heard he looked "full-term pregnant" and found gross failures in his care. His family have told us they have been failed by the system. pic.twitter.com/ccEYOlRpZO
— BBC Breakfast (@BBCBreakfast) February 8, 2018
How did the parties who failed Richard respond to the Coroner’s verdict? Did they show contrition and apologise unreservedly?
First up, Nick Hulme, CEO of Ipswich Hospital, where Richard died his preventable death. His apology was conditional and mealy mouthed.
He said in a statement to the press, not given to Richard’s family: “I am extremely sorry that we let Richard and his family down in the last 48 hours of his life. I want to give my personal assurance that we have learned from this tragedy and improved the care and support we provide for people with learning disabilities and patients whose health is rapidly deteriorating”.
By making that apology conditional, by stipulating the last 48hrs of Richard’s life, in an attempt to manage reputation and distance themselves from the responsibility they should be taking, Nick Hulme shows how meaningless his apology is. It is about reputation management, which incidentally is why it was issued to the media and not to Richard’s family. It’s a performance, not an apology.
Julie Cave, CEO of Norfolk and Suffolk Foundation Trust said they ‘fully accepted’ the conclusions of the Coroner. I have mixed feelings about NSFT, it was after all one of their nurses, Patrick Murphy who took Richard to A&E and if it wasn’t for Ipswich Hospital’s gross failures then Richard should have survived.
To the best of my knowledge the GP surgery and Dr Tajammal offered no statement or apology whatsoever yesterday. Although counsel for the GP surgery did allude to the fact he followed the twitter feed on Friday when he couldn’t be in court in his submissions, not quite the intention of my #OpenJustice efforts but a welcome side effect. I look forward to a donation from his chambers, 2 Hare Court, to help fund future coverage of inquests.
Mike Hennessey, Suffolk County Council director for adult care, told the BBC they had “already taken significant steps to address the recommendations of the serious case review”. He said: “Alongside all organisations involved, we are fully committed to further work to improve the health and social care services provided to people with learning disabilities in Suffolk.”
There we go again, distancing, alongside others, it wasn’t all us guv.
So, finally, what of Richard’s ‘care provider’. Tim Cooper, CEO of United Response, who ran Bonds Meadow where Richard lived and whose failings led to Richard developing the faecal impaction that ultimately killed him. Was he full of genuine remorse and apology? He addressed the waiting cameras and said: ‘There were a number of agencies involved in Richard’s care and I think that we all have to accept that there are things that we should, and could, have done better and certainly as United Response we accept that’.
Oh my goodness, Tim. I get that you’re fully aware you’ve had a lucky escape, of course you were expecting a conclusion of neglect, we all were. There really is no room for distancing and weak excuses – United Response failed Richard. Own that, say sorry, apologise completely. Instead we get distancing, wasn’t just us, and even worse a revealing ‘we all have to accept’ and a begrudging ‘we should, and could, have done better’.
Richard died, you should be accepting, acknowledging and owning. You should all be doing everything in your gift to make sure it never happens to anyone again and to apologise for your mistakes. Not admitting that you’re being forced to accept, and that you should have done better. He died.
In a grim day for social care yesterday, Somerset Safeguarding Adults Board published a serious case review by Margaret Flynn looking at the abuse at Mendip House, a residential home run by the National Autistic Society. I didn’t have the stomach to read the serious case review today, I’m done in for the week, but I did get as far as the first page, where this statement is written:
So, I popped over to the NAS twitter feed to see how it had addressed the publication of the serious case review, and the utterly damning findings around abuse and the failings of management and leadership. I was expecting, at the very least, a statement from Mark Lever, their CEO. I was hoping to see it starting with the words ‘I am sorry’.
There was nothing. Absolutely zilch. Instead NAS had created a new account, presumably to try and keep their distance from the abuse and horror in the serious case review. It is called ‘NAS Supporter Care‘ and it sends automated sounding responses to people. I’m honestly not sure whether it is run by a bot, or whether it is a spoof account, it is so badly done. This is an utter failure and NAS should be ashamed of themselves.
Here’s the deal people. You get things wrong. We all do. It’s uncomfortable and if you work in health and social care your mistakes can have devastating consequences. People suffer from abuse and neglect and people die. This is heart breaking and wrong, it is also very real. The only way to act in those situations is bravely.
The weak leadership on show when these failures are exposed does nothing but compound the problem. If you can not hold your hands up and own your failures, then why should anyone listen to a single word you say? Why should anyone donate a single penny to your coffers? Why should anyone entrust their loved one into your care?
Yesterday the coroner paid tribute to Richard’s family. He said that without their diligence and determination, many of the investigations into Richard’s death would not have happened. We heard throughout the inquest how Ipswich Hospital failed to disclose the MEWS scores (that ultimately proved their neglect) to Margaret Flynn when she was conducting her serious case review into Richard’s death. This behaviour is a red flag to families. It becomes crystal clear that people are interested in their own reputations and not in admitting mistakes or embracing a duty of candour.
Here’s the deal, every bereaved family I’ve met starts off reasonable. Every. Single. One.
Own up, apologise, be human and they will meet you in the middle. They may not ever forgive you for the death of their loved one, but they will not fight you. You see a genuine apology is like a superpower, it holds so much weight.
I’ll leave the final word to Emily, Richard’s youngest sister. Given their life sentence, is a genuine apology really so hard to muster?
Richard was entirely dependent on the health and social care system to exist, and now he doesn’t exist because his needs weren’t met, and we have to live with that for the rest of our lives.