As I read in Private Eye today (Fatal Failures) of another mother’s “five year battle” who’s also trying to uncover the truth about her young 20 yr old son Matthew’s death in 2012 from ligatures in an Essex NHS institution a week after being admitted, I wondered how many mothers like Sara Ryan would have been able to persist for so long in the face of all the blocks and barriers put in the way (see her latest blog “Imagining a Guilty plea” Imagining a guilty plea as she prepares for Monday’s court).
It’s scandalous that we have so much effort in our ‘human’ services put into covering up – and apparently little attention put into really learning the lessons and acknowledging mistakes. We have again ‘fabricated records’ and 15 minute observations missed or not carried out…. It’s apparently led to the police investigating 25 similar deaths over 17 years.. but will they manage to uncover the truths? Despite the refusal of the Trust to further investigate following the inquest recommendation, ,who are reported have decided it has had a sufficient “comprehensive airing”, other ligature deaths /attempts have happened since eg one in 2015.
Without such as Sara refusing to be bullied out at such a personal cost, I doubt anything much would change – so we all owe a real debt of gratitude to her fortitude in persisting… and I hope we will see the proper result on Monday… and see leaders of such organisations understand how they lead, train, supervise and motivate their staff makes a real critical difference. They cannot be irrelevant to any such tragedies that happen and need to recognise that the job of supporting people in distress with complicated needs is a complex one depending on a calibre of support and supervisory staff absolutely committed to the best for each person. They need to have so many qualities including a mix of real caring, intelligent listening and communication, and a real ‘getting alongside each person’ to understand them in their context (their life experiences and family and friends’ relationships), their culture and individual needs and preferences, with a values-base that values everyone and doesn’t limit people’s opportunities and possibilities.
We can hope the current CEO’s contact with Sara was a human attempt and certainly seems to show more humanity than previously encountered. We do seem to see too often a large organisation’s immediate instinct to deny everything and cover up wherever possible. Perhaps they are seduced by their distance from reality and experience of hearing what they want to hear by insisting on the ‘outcomes’ they prescribe, successfully intimidating their workforce to report what they want to hear. Driven by their wish to protect their “reputation” and their investors where they exist, it feels as if they have lost any connection with their purpose – supposed to be to help human beings. In fairness this is not helped by their direction from the insurance companies whose motivations are to minimise any damages they might have to pay out. We must hope that any findings result in massive damages payments so that insurance companies understand they need to learn better that what really protects them is best practice and practice that espouses and motivates values underpinning best practice throughout the organisation, that includes everyone and doesn’t exclude families so as to hide behind closed doors. Insurers need to weight their risk by understanding the real risks of the closed institution.
Thank you Sara – and we can only hope that Connor’s legacy will mean more attention from the highly paid Chief Executives and Boards to understanding what leadership and scrutiny mean to their services and implementing some critical changes to what feel like some sloppy, indifferent and unsafe services. #3000lives
