I’ve been away from my laptop for a few days, ignored twitter, took some time away, swam in the sea (well more like just jumped the battering waves and felt glad to be alive and so small and insignificant in things), gave blood, visited friends, usual everyday things. Nothing wild but a break of sorts, one that feels all too short as I find myself sat at my laptop having to write this. Having, because it feels like a compulsion, a necessary requirement for the sake of sanity (mine and others) and also part of the role of witnessing.
On Tuesday 30 May, the Senior Coroner for Worcestershire, David Reid, found that Sally Lewis’s death was contributed to by neglect. I reported Sally’s inquest in detail and you can read all my reporting about it here. I also reported the failed criminal prosecution of Dimensions and the registered manager, Julie Campbell, here. I call it failed because the case failed on a technicality, before any evidence even reached court, due to the regulator, CQC’s, incompetence in bringing the case in time. The court found that there was an abuse of process, so the case was dismissed. I’ve written a stinkingly in depth piece about all the twists and turns of what happened there in this post here, but the short version is that CQC cocked up and Dimensions covered up.
Therefore the only court that has ever heard evidence in relation to Sally Lewis’s premature and preventable death, is Worcestershire Coroner’s Court. The coroner said that he was satisfied that the cumulative failure, that’s of Dimensions’ staff who should have been providing care to Sally, and their managers who should have been overseeing it, “was so complete, and so serious, it can only be properly described as a gross failure”.
The coroner made ten findings on the balance of probabilities, including that Sally had not been given one of the medications she was prescribed for constipation for 10 months before her death, and that if a proper regime was in place to monitor and record Sally’s bowel movements, Sally probably wouldn’t have died when she did.
There were no shades of grey in this conclusion. While coroners courts are not about attributing blame, they do make findings of fact, and in this case the facts were crystal clear.
The facts that the coroner found, had been supported by evidence from a myriad of sources, including the court expert Prof Ian Gilmore’s own evidence, the evidence of the Worcestershire Safeguarding Adults Board, the evidence of the LEDER report (not relied upon in the coroners court but referenced in the other investigations) and the evidence of Dimensions’ own internal investigation, to the extent that it can be considered one given the limitations that the author admitted in court.
How did Dimensions UK respond to the coroner finding them responsible for Sally’s death occurring how and when it did? With a non-apology of course, so well known in the space of social care providers found culpable.
I wrote about this non-apology in this post here. It included this comment:
It’s entitled: Our response following the inquest into the death of Sally Lewis and rather bizarrely it has a large photograph of the CEO Rachael Dodgson on it. Which is the first indicator that this is in no way either sensitive to Sally’s family, or had been in any way run past them.
Para 1: I’ll start by pointing out that any meaningful apology would start with a meaningful statement of regret. When a coroner has ruled your organisations neglect caused someone’s death, that they simply would not have died if your staff had followed the instructions given to them by a GP, if staff had made meaningful records of Sally’s bowel movements, if your managers, Julie McGirr and Julie Campbell had actually done any managing, if they’d audited the records that staff weren’t completing effectively, that Sally was wholly dependent on you for her care, and she was let down in a gross and basic way, that’s what you need to acknowledge. Your neglect.
I wasn’t the only person enraged by their weaselly words, their tactics to dismiss and deny, their total lack of transparency and accountability. The obvious question, of whether they would now cover the costs of Sally’s family’s £24k legal bill was also raised. Here’s a selection of tweets.
Why you might ask, am I writing about this again now, instead of eking out the last few hours of my week off?
I’ll explain. On Thursday I saw a tweet from Sally’s sister Julie saying that Dimensions had edited their statement, that they published after Sally’s inquest concluded.
It seems, despite not acknowledging that they are listening in any way, Dimensions are trawling social media to gauge opinion and editing their communications accordingly. I completely agree with Shazia, it reflects how Dimensions operate, and it also reflects what is important to them.
The court evidence was clear that Dimensions knew Sally had died a preventable and premature death as early as three years ago, and most likely much much earlier than that. Yet still they fought tooth and nail to avoid the accountability of the criminal courts, and to try to argue that they were not neglectful at Sally’s inquest. Those claims juxtaposed against a gazillion actions they’ve apparently made to improve things since Sally’s death. Reputation is king.
Rachael Dodgson, the Dimensions CEO, has removed her face from the statement/website, and they have added in a line about neglect. This is how it now reads:
They’ve done this without acknowledging the change publicly, without informing Sally’s family (remember this statement claims twice within it that they apologise to Sally’s family, despite not contacting them or their legal teams with the statement – at the time it was first published, or at the time it was edited*).
The Dimensions UK website doesn’t reflect in any way that the statement is edited, or the timings of the edit.
That’s before you even consider what is said “in the words of the coroner, was contributed to by neglect”.
This from an organisation that instructed their legal counsel to make submissions to the same coroner, to argue that Sally’s death was not due to neglect, or could not be considered to be due to neglect with regards to a failure to monitor Sally’s bowel movements because that failure had existed for at least two years before Sally died, claiming there could therefore be no direct causal connection between that failure and Sally’s death. They also suggested that the failures didn’t amount to a failure to provide basic medical attention.
This from a supposed specialist learning disability provider.
Murk and cover up, the total opposite actions to an organisation that claims to value transparency, see this advert for a new Board member from April.
According to Dimensions Board Member and Chair of the HR Committee Gordon Lyle:
The mission, purpose and values are not ’nice to have’s but commitments and ambitions that shine a light on who we are and how we behave. Everyone is facing in the same direction. Everyone celebrates the successes, and everyone highlights the opportunities to do better. Everyone takes ownership.
If this were true, why the silence from the Dimensions Board Members despite direct requests for comment?
and how did those same Board members respond? With silence.
We see you Dimensions. We see you Rachael Dodgson. We see you Nick Baldwin. We see you Gordon Lyle. We see you Richard Crompton. We see you Shahana Khan. We see you Noah Franklin. We see you Sherry Malik. We see you Angela McNab. We see you Huw John. We see you David Isseneger. We see you Anne Wafula-Strike. We see you Veran Patel.
We see your lack of leadership, ownership and accountability.
We see your focus on reputation.
We see your silence.
Your actions show clearly, again and again, how disposable Sally was to you, how insignificant her life was to you, how hollow and meaningless your PR apologies are.
It’s not a case of “in the words of the coroner” Sally’s death was due to neglect. It’s crystal clear to anyone who has paid the slightest attention that Sally’s death was due to failings in your processes, your staff, lack of support, training, audit or monitoring, and a carelessness and ambivalence.
That’s why Sally died. And as Board members that’s your responsibility. Remember the claim that ‘Everyone takes ownership’. About time someone did.
* Julie, Sally’s sister, has told me since this was written she received a letter via her solicitors on the evening of 7 June, she’s not sure whether the statement was updated before or after that letter was sent.