Week 6: A breath of fresh air in the inquiry process #107days

Final post this week is an update from Sara:

Bit of a shocker a couple of weeks ago when we were informed by Charlotte, our solicitor, that Sloven were going to ask for a judge to be appointed to conduct LB’s inquest. She explained how the Coroners and Justice Act 2009 allows a High Court Judge to be appointed to hear an inquest in certain circumstances. The Chief Coroner has to make a request of the Lord Chief Justice, who in turn has to consult with the Lord Chancellor, and the Lord Chief Justice can appoint a High Court Judge to sit as a Deputy Coroner who can hear inquests alone or with a jury. There is no specific guidance as to when this should happen but it is relatively rare and tends to happen in cases involving matters of national security (eg. the Litvinenko Inquiry) or when the inquest may be exceptionally legally and factually complex (eg. the ongoing Hillsborough inquests).

LB, love him, was not really a matter of national security (though this request would put a bounce in his step forevermore) and really it ain’t exceptionally complex what happened. Our hearts sank because of the delay that it could cause. The inquest is currently arranged to start on October 5th and the thought of it being put back even further was fairly harrowing.

We were all pretty baffled why and on what grounds (two separate things) Sloven would make this request. The what grounds was answered by the five page letter to the Chief Coroner, dated 24 April, which argued that LB’s inquest may well have far reaching implications for the care of young learning disabled adults in the future. Well here in the Justice shed we certainly hope it does. That is the aim of the campaign after all. The letter went on to detail and provide links to our social media activity including Norman Lamb’s Lib Dem Spring conference speech.

Bizarrely, having argued against an Article 2 inquest in an earlier pre-inquest review meeting on the basis that there have been so many reviews into LB’s death, Sloven’s solicitors made the case in the letter that the volume of evidence gathered by the various reviews will make the inquest legally and factually complex. Ho hum.

The now familiar heavy weight we seem to carry with us increased (again) and we steeled ourselves for further, relentless, delay.  Three days later, remarkably, the Chief Coroner replied turning down the request. He acknowledged that the inquest may have wide reaching implications for the care of learning disabled people, but he didn’t think it would be exceptionally complex and bringing in a judge would involve delay. Wow. It was like someone had opened the door to the musty, dark, dank old cell we’ve been stuck in for 21 months now and blasted a load of fresh air into it. A response/action in three days? That is exactly how the system should work. The door shut again but we were left feeling brighter and with the most poignant typo in the letter:

The Chief Connor has read your letter about the events surrounding the sad death…

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I hope LB is somewhere, somehow. Because his dreams continue to come true in the most fantastical ways. 

Week 6: Ecoutez et repetez #107days

Continuing our week exploring inquiries, today’s post comes from Chris Hatton

When I was a PhD student, the common room in the research centre where I ‘worked’ (yes, there were such things in the olden days) contained an unremarked upon filing cabinet. One idle afternoon (yes, there were such things in the olden days), out of curiosity, I opened it, to find an anti-Narnia of dusty inquiry reports. The rest of the afternoon went as I started reading through them, my shiny, unthinking bubble of an optimistic perpetual present (what history?) gradually deflating and then popping altogether. I consoled myself that this was all in the sepia-toned, bad, institutional past, though, and people with learning disabilities were on the path to a bright and better future (cue heroic socialist realist poster). As a metaphor for the history of inquiries, it’s so perfect as to be completely unconvincing.

Some quotes (and for more from recent inspections of ‘specialist’ services for people with learning disabilities see here):

  1. ‘Our investigation found that institutional abuse was widespread, preventing people from exercising their rights to independence, choice and inclusion. One person spent 16 hours a day tied to their bed or wheelchair, for what staff wrongly believed was for that person’s own protection. One man told investigators that he had never chosen any of the places he had lived as an adult’ Full report
  2. ‘The families of patients at Winterbourne View Hospital had no experience of being regarded as partners, deserving of trust and respect, or even of collaborating with Winterbourne View Hospital staff. Theirexpertise, borne of the lengths to which they had gone to keep their relatives at home and in care services, was not acknowledged by Winterbourne View Hospital. They were excluded from having a full picture of events at the hospital’ Full report
  3. ‘An unduly casual attitude towards sudden death [and] inadequate systems for reporting incidents’ Full report
  4. ‘1991: Allegations of assault. Investigations were made and evidence established, but the Inspector chose not to use the enforcement powers of the Act.
    December 1992 – April 1993: Allegations of multiple abuse. The evidence of abuse increased and the Inspectors accepted that there was a serious case to be answered. But no assessment of the risk to residents was undertaken nor were the police called in to help. Fearing intimidation of staff and residents, the Inspection Unit continued to rely on announced inspection visits.
    1993: Joint Police/Inspection Unit Investigation. There was no common understanding of the strategy to be followed. The Inspection Unit decided to take no action unless and until the Police decided not to prosecute. They failed to assess the evidence as it became available and so suspended their duty to consider whether enforcement action was needed.
    1994: The Inspection Unit Investigation. This was an extremely complex investigation for which the Inspectors had little experience. They did not seek help from the Health Authority, renew contact with the Police or use other specialist sources. Complaints about specific aspects of the care regime were never properly investigated. Social workers, families and the police were given no information about specific allegations.
    1994: Action on the Inspection Unit’s Report. The advice to Social Services Casework Sub-Committee not to take enforcement action under the Registered Homes Act 1984 to cancel the registrations in respect of the homes, as summarised in the final report which was put to the Social Services Sub-committee, did not reflect the professional judgement of the Inspection Unit’ Full report
  5. ‘For long periods of time the hospital buildings were neglected and dangerous. They were a patchwork quilt of makeshift repair and poor workmanship. The roof of the main building let in water for many years and the upper floor often had to be evacuated because rainwater poured in and it was feared that the ceiling would collapse. Patients were sometimes soaked as they slept. Buckets and tin baths littered the upper corridor…The standards of hygiene were often appalling and patients and staff alike suffered from demarcation disputes between nursing and domestic staff. Faeces and urine were frequently left unattended for days on end, with consequent risk to health and welfare of patients and staff’ Full report
  6. ‘Some individuals, as the trust has acknowledged, have suffered abuse including physical, emotional and environmental abuse. The trust’s own investigations at Budock Hospital have shown that some people using its services have had to endure years of abusive practices and some have suffered real injury as a result. For example, one person suffered multiple injuries over time, including a fractured skull after being hit by another person who used the trust’s services. Despite the development of numerous action plans, underlying problems have never been addressed and poor practice has become ingrained within the management of learning disability services and the provision of care’ Full report
  7. ‘There were examples of individual patients in Winterbourne View Hospital and their families being threatened with the improper use of mental health legislation’ Full report
  8. ‘All the male wards are seriously overcrowded. The buildings are old and ill-designed. The standards of amenity fall far short of what would nowadays be expected…The staff establishment [of one ward] is half the minimum desirable…’ Full report
  9. ‘The standard of nursing care was generally extremely low and the quality of life of many of the patients suffered accordingly. Shortage of staff at different levels was at various times a contributory factor, but it was by no means the principal cause of difficulty’ Full report

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A few observations from me. First, as the #JusticeforLB #107days inquiry timeline and Katherine Runswick-Cole’s post make clear, these successive inquiries, serious case reviews, independent investigations and inspections (46 years on from Ely Hospital now, almost as old as me!) have not resulted in the eradication of abuse of people with learning disabilities in ‘care’ services.

Second, these inquiries are clear-sighted about identifying the ‘causes’ of the abuse and poor practice reported time and again, but they generally do not try to get to what Sir Michael Marmot in a public health context calls ‘the causes of the causes’. We know that smoking causes lung cancer, but wouldn’t it be equally important to know why people take up smoking in the first place? These inquiries tell us what seemed to contribute towards abusive practices in each place, but not to address what causes these factors to recur, again and again.

The Utopia of Rules by David Graeber (see a long post on my reading of this here for a detailed expansion of the argument) struck me forcibly as providing part of an answer to this question. One of his central points is that bureaucracies can draw on (and indeed rely on) the threat of real violence for their enforcement. So, is the abuse reported in inquiry after inquiry a logical end-point, or a necessary element, of an intensely inhuman, bureaucratic ‘care’ system?

Is it also possible that the ‘failure’ of inquiries to eliminate abusive practices (and not just in services for people with learning disabilities, as this slideset from Prof Kieran Walshe makes clear) is partly because the recommendations they make are all about tinkering with these inhuman bureaucratic systems rather than seeing them as part of the problem and tackling them head on?

So, where might we go from here? Whenever I see a service really working for a person with learning disabilities, there’s always a person with a strong, human commitment to making whatever they’re doing work better for people, no matter what bureaucratic system they’re enmeshed within. Some people just seem to ‘get it’, and have the energy to bend/break bureaucratic systems to create a bubble of humanity within these systems. Why doesn’t this happen everywhere? I used to think part of the issue of ‘scaling up’ good practice was to design systems better so that good practices in a place could survive the committed person moving on. I now realise this was completely wrong-headed and bureaucratic as a way of thinking. Now I think what we need is to find, nurture and support as many ‘humans’ as we can to start to shake and dissolve the inhumanity of bureaucratic systems. A service needs to start without the bureaucratic threat of violence in its back pocket, for genuine, human relationships of trust to develop.

Sources
1, 6: Joint investigation into the provision of services for people with learning disabilities at Cornwall Partnership NHS Trust, 2006
2, 7: Winterbourne View Serious Case Review, 2012
3, 8: Ely Hospital Inquiry, 1969
4: Independent Longcare Inquiry, 1998
5, 9: Normansfield Hospital Inquiry, 1978

Week 6: Do we need another inquiry? #107days

Here in the Justice Shed we’re quite responsive and organic in our approach to campaigning (which really means we aren’t amazingly good at forward planning and fly by the seat of our pants a little), one of the advantages of this is that we can respond to issues as they emerge. A tweet from Katherine Runswick-Cole and a blogpost from Chris Hatton stopped us in our tracks this week, and we decided to embrace the discomfort of them and make Week 6: Do we need another inquiry? week!

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A potted history of inquiries into abuse and mistreatment of learning disabled people in the UK follows:

1967, Ely Hospital Wales:

Conditions at Ely Hospital came to the attention of the world through the pages of the News of the World. It reported allegations of ill treatment of patients and pilfering by staff. The allegations were made by a nursing assistant at the hospital… The public outrage which followed led to the setting up a committee of inquiry…It was Howe who insisted the inquiry should go far beyond the events at Ely itself, to look at the whole system and the way in which people with learning difficulties – “mental handicap”, as it was known at the time – were treated within the 20-year-old NHS.

Nationally, the impact of events at Ely was profound. From this time onwards, the momentum to close the long-stay hospitals and to resettle patients in the community gathered unstoppable pace.

It wasn’t until 1996 that Ely eventually closed, a mere 29 years after the horrors first became known about.

Fast forward to 2007 and an almost identical scenario was uncovered at Orchard Hill Hospital in the London Borough of Sutton. Yet it took a further two years before, in 2009, Orchard Hill eventually closed, and even then some residents remained on site in bungalows awaiting purpose built community accommodation. Forty two years after Ely.

In between times, there were ‘scandals’ of abuse uncovered in Longcare in 1994 and Budock Hospital in Cornwall in 2006.

In recent times we have the Panorama uncovered abuse at Winterbourne View in 2011. At this stage we can take a look at a timeline that Sara put together to situate what happened to LB, within the ‘national outcry’ post-Winterbourne:

Sara_revised-timeline

The ‘post-Winterbourne’ era is marked by what can only be described as an apathy, everything is too hard or too complex. Everyone merrily talks about the shock and shame, hands are wrung up and down the country, and while some individuals and organisations work their socks off trying to get people out of ATUs, a larger group with vested financial interests join committees and reports, that seem to get us nowhere.

Earlier this year, in February 2015, the National Audit Office reported on Care services for people with learning disabilities and challenging behaviourA grilling by the Public Accounts Committee revealed Viv Cooper of the CBF to be just about the only person who appeared to both understand the task ahead and be passionately committed to closing ATUs now, rather than to be overwhelmed at the scale of the task or reluctant to commit. The Committee didn’t of course meet any experts with a learning disability. Our campaign responded to the NAO report with our own audit Actually improving care services for people with learning disabilities and challenging behaviour.

So the question of this week’s #107days is ‘Do we need another inquiry?’.