All week we’ve been sharing some of the lowlights from LB’s inquest a year ago. Sara has blogged about how this strange anniversary feels for her and the utter despair at the complete absence, still, of anything vaguely resembling accountability:
I think my new tear configuration has (re) emerged because of the utterly shameful banality of the public sector response to what has happened. A year ago an inquest jury determined that LB died from neglect. He should not have died. He was effectively killed. And nothing has happened. And a recognition that this sustained cruelty can’t continue indefinitely. We (a collective #JusticeforLB we) could not have done more to counter the darkness of the #NHS and social care at its worse, with light. And brilliance. And there is still no accountability.
I sat through two weeks of LB’s inquest, every single minute and live tweeted as much as was possible when the jury were sitting. I’ve said several times since that if I’d not sat through it I wouldn’t have believed it. I can say the same for so much of what Connor’s family have been subjected to.
Pouring over the tweet archive has been illuminating to say the least, in some ways it’s like I was reading them for the first time, and in others they served as visceral bullets shooting me back into the tension of that Coroners Court a year ago. I wanted to just reflect on a few of the things that came up in the first week in this post.
Twitter has its limitations and 140 on a screen can’t even being to touch on what this was like:
WB wants to say something to @sarasiobhan before Paul Bowen questions her. 'I'm so sorry that I failed Connor and your family'
— LB's inquest (@LBInquest) October 8, 2015
Day 4 of LB’s inquest and from where I sat the first and only example of true candour, but it was *so* powerful. Winnie, one of LB’s two named nurses, turned in the dock, looked straight at Sara and Rich, took a deep breath and through tears apologised. She did not deny or diminish or avoid her responsibility. It was almost like there was an electric charge at that moment.
To this day I don’t know how Sara, Rich and Connor’s loved ones managed to find the grace to hear and acknowledge her apology, but they did. In fact after the various legal teams had finished questioning Winnie, at the next break Rich (a true giant of a man) went to speak to her legal team to thank her for her honesty. Later on I met Winnie, bundled into the family room, where more tears were shed as she recounted her regret and apology once more.
The facts don’t change, Winnie was one (of many) who made errors that led to LB’s death, but the shared humanity won out. Candour, when it really exists, when it’s about humanity and regret and honesty, is a very powerful thing.
It’s also incredibly rare.
Less rare was the relentless attempts at mother blaming. All of the witnesses employed by Southern Health had this rather odd section in their statements entitled ‘relationship with the mother’. Variously addressed as mum, Dr Ryan, Mrs Ryan and ‘the mother’ staff were
coached, nah encouraged, let’s stick with ‘asked to reflect’ about their relationships with Sara.
There was no request made to reflect on their relationships with LB’s father, or any other relatives; neither were there sections about their relationships with each other, different departments, managers or indeed the IT system. Nope, the focus was firmly on Sara.
As it unfolded Alan Jenkins, counsel for Dr Valerie Murphy the psychiatrist who insisted (throughout the inquest and I imagine to this day) that LB did not have any seizures during his time on the unit, was particularly obsessed with the relationship between Sara and various unit staff members. Asking witness after witness how they ‘found’ Sara:
In the middle of the week we heard from the Charge Nurse Jonny Cowee who had this to say about how the psychiatrist spoke about and described Sara:
As Chris Hatton expressed at the time the ridiculousness of it all was that the mother blaming itself was contradictory, on one hand there were complaints that Sara didn’t tell them what to do, and on another how dare she tell us what to do. Remember that bereaved families aren’t routinely entitled to legal aid, in fact the argument is made that inquests are non-adversarial, yet this is the legal representative of the psychiatrist trying to paint LB’s mother as the problem. I kept notes of some of the discussions that happened in the court room when the jury weren’t sitting, it included this comment:
Southern Health’s barrister attempts to point out that an inquest is an investigative not adversarial process – not that you’d feckin know it given their behaviour.
Enough said. Can you even begin to imagine what it would be like to be sat in a court with 16 witnesses giving evidence into the death of your child, with 9 jury members and 7 legal teams and to sit there, alone, without any legal support.
Contradictions and forgetfulness
The inquest transcript is littered with these contradictions, absences and (selective) forgetfulness. Staff contradict themselves within their statements, between statements (those given to the Court, to the Police, or to the independent investigators). Staff forget, some things you can imagine you would forget, others just seem very conveniently and strategically forgotten. A sort of unique brand of candourless amnesia.
This amnesia was often accompanied with a sort of professional indifference:
A registered nurse Keiran Dullaghan, providing specialist care, speaking at the inquest into the death of a young man, sort of casually mentions that they ‘wouldn’t wholly follow’ the policies. So blasé.
Don’t we know it. It’s why the Southern Health continual retort that they have a policy and an action plan in place is so utterly worthless.
Chuck into the mix the fact that any witness can refuse to answer if they’re likely to incriminate themselves in a criminal investigation (either Police or HSE in this case) and if I were a family member I would be left asking what is the point of this legal performance.
The final observation from reflecting on the first week is just how unprepared some of the staff witnesses were. Not in how to perform, how to avoid giving too much away, how to protect themselves, the ‘inquest coaching’ had done them well on that front. Lift the lid however, scratch just a teeny tiny bit under the surface and it was utterly woeful how little the staff appeared to know about epilepsy, despite this being an inquest into the death of a patient with epilepsy who drowned in the bath, and despite Southern Health’s repeated bleatings that all staff had been trained and up-skilled in the wake of LB’s death.
This happened on Day 3:
and this on Day 4:
and this on Day 5:
Epilepsy is not uncommon, about one in four learning disabled people have it, these staff work in a specialist service for learning disabled people. Yet they can not describe the basics. Despite the gold standard award winning training rolled out across Southern Health.
How can it be?
How can any family be expected to sit through this? How can it be an acceptable tactic that bereaved families can be blamed and pulled apart in open court? How can people care so little they don’t even cover the basics? I’ll blog again next week about some of what else was uncovered, but can’t leave week one without mentioning the utterly hideous revelation that emerged, not at the start, no forget about candour, but on Day 5:
Nothing could prepare us for the revelation, half way through an inquest, after four pre-inquest review meetings, two external investigations and a Police investigation, when a member of staff suddenly reveals that a patient had died in the same bath, seven years previously.
The only reason this came to light was because the psychiatrist was using it as a bargaining chip. It appears she chose to remember and mention it (when every one else had forgotten, including two staff on duty when that patient died, including the doctor who wrote his death certificate). Who knows what ‘jogged her memory’ but I can guarantee you it wasn’t candour or honesty, and it might have had something to do with hoping for a delay to allow her to leave the country – indeed her giving evidence was delayed and she ended up returning to Ireland and giving evidence via video link. Southern Health had forgotten to mention this death to their own Barrister, who was as on the back foot as the rest of us. What sort of ‘honesty’ is that. Sara’s blog post about this revelation ends:
We’re left wondering what else hasn’t been disclosed? How often does this level of cover up happen within the NHS? And was there any point to the Francis Inquiry?
A year after LB’s inquest concluded, after visiting the tweets from that time I’m left with all of those questions, still. The #CQCDeathsReview when it is published later this year should touch on some of this. As for what hasn’t been disclosed at Southern Health, I’m not sure we’ll ever know.
The question I keep returning to, like some scratched candour record stuck on repeat, is what is the point of NHS Improvement? Where were they a year ago, where are they now? What is the point of the NMC and the GMC? Why does everything take so long. The inquest happened a year ago, they could have sent representatives to listen in, they have copies of the recordings taken, it would take 10 days maximum to listen to them. Those recordings are absolutely dripping in evidence of failure, yet nothing changes. Can anyone explain that to me, please? How many more deaths, inquests and families being destroyed will it take?