The life and death of Richard Handley #OpenJustice

I’ve spent the last fortnight in Ipswich, live tweeting the inquest of Richard Handley, a young man whose life was cut short in it’s prime, aged just 33. I’ve spent break times with Richard’s family in the court jury room, listening to the telling of tales and the sort of family folklore that we’d all recognise from our own lives. The ‘do you remember when’ and the ‘what would Richard say to that’, the laughter and the pain, the reminiscence and the desperation. I’ve repeatedly asked the question ‘how could they’ or ‘but why didn’t they’, silently more than aloud as I’m mindful of not laying yet more questions and irritations on a family who have fought so hard to get to this stage. The questions in my brain are on loop though, a permanent feature.

I’ve listened to every single minute of every single witness who has addressed the court. I’ve watched the counsel circling, stalking and pounce. I’ve mused the line between inquisitorial and adversarial. I’ve been deeply reassured by the humanity and fairness of the coroner, Dr Peter Dean.

Richard’s family

As I see it, there were several key players in the life and death of Richard Handley. First up were a truly loving, devoted and desperately ordinary family. Just like yours or mine, extraordinary in their ordinariness.

Richard’s family clearly loved him, cared for him and advocated to ensure his dietary and health needs were understood and addressed. If you looked at Richard on paper he ticked all the boxes, he was pleasant and amenable, a cheeky chappy with a wicked sense of humour [not that this should matter to the level of care provided to him of course, but it is context], he had strong health advocates in his family members. Richard was on his GP learning disability register, he had some annual health checks, he had a hospital passport. Mention an initiative to ensure learning disabled people can successfully access healthcare and Richard was engaged with it. And yet still he died.

Mary Beard

At the end of last week the coroner suggested that the process of an inquest, was as important, if not arguably more important than the conclusion he reaches at the end.

This weekend I read a great Guardian Long Read, The Cult of Mary Beard. I’m a long time fan of Mary Beard, I admire her relentless commitment to discussion on twitter, I found myself nodding along to this article. As someone who has invested countless hours on social media over recent years debating and discussing the premature deaths of learning disabled people, it felt almost grounding to remember that it’s okay to do so:

Beard’s intellectual style, which suffuses all her scholarship – a commitment to rigorous scepticism that refuses to be cynical – has made her a model for those who worry that the shouting and bullying of the digital world make reasoned political debate impossible… Embedded in her refusal to be silenced, in her endless online engagement, is a kind of optimism: the idealistic, perhaps totally unrealistic, notion that if only we listened to each other, if only we argued more cogently, more tolerantly and with better grace, then we could make public discourse something better than it is.

Colleagues of Beards discuss her style, the emphasis on the process, the dialogue, the discussion and not ‘the thing’ itself. I couldn’t help but draw parallels to the coroner’s reminder about the inquest process, the value in hearing and interrogating the evidence put before him and the court.

Medical care

So who are the other players in the life and death of Richard Handley. There’s his GP surgery that had provided primary care to him throughout his life, Bridge Road GP Surgery in Lowestoft. Associated with them, but an independent interested party is Dr Romana Tajammal, a third year GP trainee who did a home visit to Richard days before he died and prescribed laxatives. Alongside the primary care providers are a psychiatrist Dr Salman Ahmad [currently living in New Zealand and who will hopefully be providing written evidence to the court this week] and staff at Norfolk and Suffolk NHS Foundation Trust. NSFT also employed Mr Patrick Murphy, a learning disability nurse who worked at the ATU to which Richard was admitted days before he died. Well strictly speaking he wasn’t admitted due to the actions of Patrick Murphy and Dr Rhana Theruvath-Chalil the SHO, who recognised the seriousness of the situation and took him straight to the emergency department at Ipswich Hospital.

Ipswich Hospital are another one of the seven interested parties. It seems that the immediate care was of an acceptable standard, possibly even good, however a failure to recognise Richard’s deterioration, to respond to the MEWS scores [which as an aside they failed to provide to the people commissioned to conduct the Serious Case Review] or to escalate to the intensive care team/for senior review meant that Richard died. Something that we heard, on the balance of probabilities, should not have happened.

The council

Another key player in Richard’s life and death, are Suffolk County Council who commissioned, and paid for his care. To me the evidence is crystal clear, Richard was collateral damage of a policy drive move to Supported Living from residential care. The drivers for this policy change locally seem to have been cost cutting hidden behind an ideology of independence and autonomy. To be fair, Suffolk CC have admitted their failings, their only witness Mr Peter Devlin, came across as genuine and regretful [a comment that should tell you something about some of the other witnesses given this was noteworthy]. The council failed to manage or monitor the change to supported living, various witnesses have suggested that support around Richard ‘fell away’, as commissioner it was the council’s ultimate responsibility to ensure that didn’t happen. They failed.

The care provider

So finally, to United Response, Richard’s ‘care provider’. The fact finding journey in relation to the care Richard received, is heart breaking. For many years he received excellent care at Bonds Meadow, as ever that seems to have been down to some brilliant staff, such as Clara Paolantonio-Hoad:

For some reason best known to United Response and United Response alone [my best guess is money saving] Clara was made redundant. What followed was a dissolving of the care, structure and process in place to keep Richard safe, an erosion of the knowledge that was held about Richard. The care home manager that followed Clara gave evidence about how they didn’t have a problem with Richard’s bowels, completely failing to see the very direct link between the non-care and attention they paid and the ultimate devastating consequences.

In many ways it reminded me of Dr Valerie Murphy’s continual refrain at LB’s inquest that Connor wasn’t having seizures, despite an inquest being held after he drowned in a bath following a seizure.

There’s none so blind as those who will not see.

Counsel for United Response did his best to exonerate them. He did of course have to get into evidence that United Response are a charity. For the record that doesn’t lessen your responsibility. In fact much like Mencap, who still claim to be the leading voice of learning disability, if you’re claiming charitable status, inferring that somehow being a charity should paint you as a good egg, it’s time to take a long hard look at yourselves. Are you really leading the way? Is your provision exceptional? Do you live by your values or are they just plastered over every surface in your corporate headquarters? Are you quietly working to improve the life experiences of learning disabled people, rather than constantly being seen to be good at something? The fact hasn’t escaped me that the CEO of United Response when Richard died was one of the invitees to Bubb’s breakfast backslap. Yet another wasted opportunity, built on ego and bluster. Not one of those in attendance thought it inappropriate that there were no learning disabled people at breakfast, speaks for itself really.

So, counsel moved us to the future. Of course it’s important to understand how much work United Response have done since Richard’s death. The thread below [if you click on it a new window will open with the entire thread] details some of the discussion, AI is Ashley Irons from Capsticks, counsel for United Response and MC is Mike Crowhurst one of the Directors of United Response:

Here we are, at Richard’s inquest, over five years since he died and it’s a golden opportunity for United Response to hold their hands up, show humility and grace, apologise and reassure us all about the learning that now runs through the core of their organisation.

What did we get? Slopey shouldered defensiveness and a woeful level of knowledge, that’s what I got from what I heard at least. First of all Mike talked about paperwork [without acknowledging that there was a lot of good paperwork in place when Richard moved to Bonds Meadow], then he lightly scattered something about mental capacity into the conversation, before attempting to shift blame to Suffolk County Council. He claimed that ‘with us, they had been on a journey’ do any of these people actually think about the family members sat listening to this?

According to Crowhurst the council are now better at monitoring, so care would be better. To my mind this argument is weak, woefully weak. It’s like whenever people get irate and angry that CQC haven’t managed to ensure care is good/safe/dignified or what have you, the logic parts of my brain start alarming, CQC are like the fire brigade, we don’t blame them if they don’t get to a fire soon enough to save someone. We tend to focus more on the cause of the fire. When it comes to care it seems acceptable to blame the regulator, or the commissioner, for not monitoring, rather than the care providers for not providing safe care. Don’t get me wrong, as the people paying for care Suffolk CC failed Richard too, but that doesn’t absolve United Response of their duty to provide safe care.

What then followed was farcically embarrassing. Irons attempted to lay the ground for Crowhurst to give us all a mini lecture on values based provision, government policy and the development of person centred care over the past decade or so. What actually happened was Crowhurst had to keep referring to his ipad to remember what policy documents he was referring to, he missed the key points of all of them, and he said nothing useful whatsoever. The reliance of words like ‘plethora’ and ’emanates’, alongside a fairly aggressive and defensive manner, just gave a disjointed presentation, a person trying to be clever, but really not giving that impression at all. Whenever this happens another bit of my brain wants to explode, we’re talking about a care provider that works with learning disabled people, think about them, channel them, use simple words and just say it as it is. Here’s a starter for ten:

We’re sorry, we failed Richard. We made mistakes. We didn’t support or train our staff properly. We wanted to keep the contract when the move to Supported Living happened, and we falsely assured people and their families that care would not change. This wasn’t the case, with devastating consequences for Richard. Policy moves in the learning disability world have focused on giving people more choice and control, what we failed to do was consider this in light of Richard’s needs or abilities. We’re really sorry and we’d like to work with you to make sure that this doesn’t happen to other people we support.

To return to the coroner, and Mary Beard, if the value of an inquest is in the process, the exploration of fact and perspective, then it’s been a useful fortnight. Richard’s family, more than any of the rest of us, has have to adopt an open mindset, listen and consider perspectives shared that sadly didn’t have Richard at their heart. The evidence the court heard is available for us to explore on the twitter feed @HandleyInquest. An inquest is not about blame, however the coroner does get to draw his conclusions.

The issue of neglect

In legal submissions at the end of last week, the notion of neglect was raised. Dominic Ruck-Keene’s on behalf of Richard’s family laid out why they considered that the coroner should be mentioning neglect in his narrative verdict. I urge you to click on the tweet to open the thread to read DRK’s argument in full (or as close to full as I could type). The impact of failings felt by Richard was cumulative, so it is not appropriate to just argue that individual component parts did not amount to neglect, something that each agency did, in front of Richard’s family:

In response, various counsel suggested the coroner could not find neglect. Beatrice Collier for Suffolk CC made the argument that the coroner could not attribute Richard’s death to neglect because it would need to be due to a systems failing and neglect could only be used if it could be pinned to one agency. At least that was my interpretation of what was suggested, again if you click on the tweet you can read the whole thread:

Every ounce of my soul felt for Richard’s family, sat in court as legal teams attempted to shrug off their responsibilities. Sheila, Richard’s mum, tweeted what all of us were asking ourselves:

Dominic Ruck-Keene’s response was one that makes perfect sense to those of us all too familiar with these systems failings, click on the tweet to open the whole thread:

I’m not sure what conclusions Dr Peter Dean will draw. I hope he will be brave and courageous and draw a conclusion that will undoubtedly be unpopular for many parties present, but to my simple non-legal brain, is the only possible one that can be drawn. I am certain that anyone who explores the evidence presented to the court can’t fail to understand how systems neglect contributed to the life and death of Richard Handley. The interested parties might be able to throw responsibility between them, but Richard and his family need to live the rest of their lives with the consequences.

Returning to the Mary Beard article, Richard’s family have engaged optimistically, they have worked hard to ensure the circumstances of his death are explored, that opportunities for learning are identified and that others are safer as a result. They have sat in the Ipswich Coroner’s Court and listened to each interested party, they have argued cogently, tolerantly and with better grace than any other entity. They have contributed their part to the public discourse, it now sits with the rest of us to ensure that Richard did not die in vain.

ps If you’re working for a comms team in one of the interested parties reading this, or the live tweets, please consider making a donation to our crowdfunding to ensure future families get a similar level of exposure to their loved one’s inquest…. it will help us all learn more and work together to improve things

8 comments on “The life and death of Richard Handley #OpenJustice”

david Wilberforce says:

excellent summary George. It seems to me that no-one beyond Clara (& his family) had or took any responsibility for Richard’s well being, so I guess it was inevitable that they would approach the inquest in the same way – by avoiding responsibility. I’m with you in that there can only be one verdict, that of systemic failure & neglect. I’m sure the individuals in the system are not in themselves particularly bad people but a poorly organised & managed system can make good people do bad things. This inquest has been an edifying experience.

Andrew Reece says:

Comment 1:CQC as Firebrigade analogy.
Fire Birgades across the country made strategic decisions to focus on preventing fires. One of the reasons Grendel was so shocking is the significant decrease in fire deaths. So I want to take your analogy further and argue that CQC need to adopt a clear corporate aim to reduce the harm caused by neglect and abuse in registered care settings.
Having made that commitment they should sit down with all their stakeholders and agree how they can achieve that.

Andrew Reece says:

Comment 2:
I think there is another layer of analysis, akin perhaps to a root cause analysis, that I think you have omitted. The common theme for both United Response and Suffolk CC is the requirement, as a result of 10 years of austerity, to save money year on year. How many of the system failings would not or might not have happended without this continual shrinking of resources. How many commissioners, providers and LD teams are reading this and thinking it could have been them in the court room because they’ve had to take unpalatable decisions.

Andrew Reece says:

Comment 3
As some one who works in an LD service I think we all need to stand up and take responsibility for the quality of the care and support we as the representatives of the NHS or Local Authorities commission.
20 years ago most care and support was delivered in the statutory sector. There would have been no passing the buck between organisations: the ‘system’ would have been 1 organisation, so there would have been less cracks to fall through.
Outsourcing care and support should not be about outsourcing risk. If we commission a service we must continue to own those risks and ensure quality.

Kara says:

Andrew, the inquest heard that the shift from ‘care’ to ‘supported living’ for Richard started in 2007/8: before the financial crash and before austerity.

This isn’t about economics, it’s about ideology ; about taking a laudable idea (independence, i.e. having the support you need to be in control of your life) and deforming it into independence-as-(unattainable)-self-sufficiency. Yes, there was a financial advantage for the Local Authority in switching to supported living in that giving residents ‘tenancies’ meant the LA was able to shift some of their costs to central government via claiming Housing Benefit for tenants’ rents, whereas care was all payable from the LA budget. The downgrading of Richard’s care, however, began even before the switch. Residents’ care plans were ‘condensed’, without understanding or thought, while the registered manager of the care home was on maternity leave. It’s highly doubtful that Richard should ever have been asked to sign a tenancy at all, as a proper assessment of his capacity would probably have precluded his holding a tenancy in his own right. The dumping of much of the information about Richard meant that he had no chance of having his health needs met thereafter, whatever the state of the economy.

The drive towards ‘supported living’, even for people for whom it was not appropriate, came from the local authority, and the lousy implementation was down to a provider colluding with that local authority to get it done on the cheap, ignoring individual needs. The couldn’t-care-less-ness that led to Richard’s death preceded austerity, however much its effects may have been exacerbated by austerity in the years since he died..

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