A preventable Death #justiceforLB

There have been lots of brilliant blogs and reactions about the report into the death of Connor Sparrowhawk (LB as he’s known through his mums blog) But, I thought I’d add to the mix…

I’ve been so incensed and angry this week and while my ramblings will be nowhere near as eloquent as the rest of the blogs I’ve read I feel compelled to get my thoughts down because I knew and loved this “dude” …in the Pride of Mother Lions that we are …he was one of our “cubs”

This week the report into Connor’s  death was finally made public. ….Lets park the fact that his family have been sitting on this, unable to share for a while now and what that must have done to them…but it’s worth mentioning here I think.

A number of things struck me in the report.

1) There’s the obvious, common sense stuff of course… that a young man with learning    disabilities and epilepsy shouldn’t have been left in a bath unsupervised …a bit like a  putting a toddler on the motorway and then wondering why he was hit by a car!

2)  The fact that this is an organisation that purports to be “Person Centred” in its      approach. On their website they have a member of staff (From STATT, where Connor died) talking about the use of Essential Life Style Planning (ELP) and yet, in the report they are put out of kilter because advocates from OxFSN start running a meeting this way. A pretty usual format used in learning disability services and one which we had no reason to think they wouldn’t be used to.

The report stated:

Comment The format used by the family support network was not one used by the professionals in the unit. It was a version of person-centred planning rather than a usual NHS CPA. A person-centred approach is well tried and appropriate in learning disabilities services and could be combined with a CPA format.

3) If they had really been used too and skilled in person centred planning they would have known about “important to and Important for” ….the key person centred thinking skill.  They would have been able to balance the fact that “having long baths was really important to Connor but supervising him was important for him to keep him safe”… actions and person centred risk assessments could have been produced from this single fact.

4)   The family are a key resource when supporting someone. They have knowledge, skills and expertise…they have built these up over a lifetime and know and love their son/daughter/relative …they have their best interests at heart!…This was ignored. The family held at “arms length” seen as “difficult” and “interfering”no doubt, not “letting go”, not treating him as an adult. The staff, instead of working with the family as partners used the Mental Capacity Act (wrongly) against them!

5)   The Trust inspected the service. They did their own internal inspection and found all to be okay.  You have to worry what they think okay looks like!

6)  The Commissioning Authority also inspected (in December 2012)  prior to Connor’s admission in March 2013 and according to them…. found all to be okay. This leads me to worry about the just what is deemed okay from a Local Authority perspective and how closely they monitor and inspect the services they are using our money to commission (I’ll be asking these questions next week when I meet with them!)

7)  The Unit was deemed non compliant on a number of issues after a CQC inspection. Being Compliant is the basic requirement of any social or health care setting. It doesn’t imply quality it really is just the basics and they couldn’t even reach that! 

8)  The staff at the unit clearly though that “non interaction with patients” was acceptable and okay…well they must have done because they didn’t change their way of behaving in front of inspectors…(well why would they when their internal inspections hadn’t informed them they were doing anything wrong, even if on a human level it was bog standard, common sense. They were/are in a “caring profession and surely that means you interact and talk to people at the very least!!!)

What’s shocked me most in all of this is the Trust’s response since Connor’s death. Instead of putting their hands up and saying “we got this wrong, we made mistakes” they have made an intolerable situation so much worse by non engagement and by trying to protect their reputation. The external enquiry that they state they requested took months to get. It took a legal team to be in place and an army of people supporting the family…something unavailable to so many people. And, they were so quick to write his death off as natural causes with all procedures followed I have to wonder how many other deaths of people like Connor have gone unnoticed and unacknowledged.

Winterbourne View shocked all of us to the core, but as horrific as the abuse was there, no one died at Winterbourne View! A young man with his whole life ahead of him died through incompetence, negligence and indifference.

It’s one death too many and it has to stop now!