GeorgeJulian Profile picture
May 27, 2022 25 tweets 16 min read Read on X
This re-framing of history by Jezza and KP is ridiculous... painting her as honourable for not disagreeing with a 16yr old... then she resigned...

Let's dig deeper shall we.

A wander down #JusticeforLB memory lane... lead role for this thread is the awesome @BBCMBuchanan

1/25
9 Dec 2015 bbc.co.uk/news/av/health…

"This is the story of how the #NHS failed to question why hundreds of patients died unexpectedly... a trust that didn't talk to families, was not interested in learning lessons... senior managers who failed to do their jobs"

2/
Featuring interview with Tessa Summers parents, she died aged 20 in 2013

"there's lots of people involved paid to do a job and they didn't do it" Jim Lynock, Tessa's stepfather

Nearly 1,200 unexpected deaths not investigated over previous 4yrs

3/ A shot of a BBC interview, ...
"There is no reason why in 2015 a report like this should come out, no reason at all, the Board and the senior team are completely responsible for this, utterly shameful" @sarasiobhan

"They should go?" asks @BBCMBuchanan

4/ A woman with silver bobbed ...
"Without a doubt. They should have gone already, they've read the report" @sarasiobhan

@BBCMBuchanan describes the report as a damning inditement of one of the country's largest #mentalhealth trusts... a failure of leadership @Southern_NHSFT, a lack of transparency

5/ Michael Buchanan, a BBC rep...
@BBCMBuchanan introduces Katrina Percy as the woman now in the firing line, Mazars report said the "failure to bring about sustained improvement in the identification of unexpected deaths is a failure of leadership and of governance"

6/ A woman in a blue dress wea...
How did @Southern_NHSFT respond? By complaining about the report of course...

The report authors had said they had "little confidence that the Trust has fully recognised the need for it to improve its reporting and investigation of deaths"

7/ Screengrab from a BBC repor...
"What really worries me is there appears to be no sense that the trust is learning, that they're changing their practice and I think in the light of this report there has to be some accountability here, someone has to be held to account, at a senior level" @normanlamb

8/ Screengrab from a BBC news ...
Everyone else could see it for what it was, the failings of the CEO and her brazen denial and deflection, her refusal to take responsibility or show any leadership, for what it was.

How did @Jeremy_Hunt respond?

Said he was shocked and it was... bbc.co.uk/news/av/health…

9/ Screengrab from a BBC repor...
"totally and utterly unacceptable... that only 1% of the unexpected deaths of patients with learning disabilities were investigated"

Odd given he chose not to make LEDER mandatory or fund it properly.

As @beverleyfs1 said the findings were "just the tip of the iceberg"

10/ Screengrab from a BBC repor...
"Until there is a proper ongoing mortality review, we wont understand the scale of the problem" @beverleyfs1

[Completely agree with Bev, I've written lots about this before here if you'd like to know more georgejulian.co.uk/curated-topics…]

No statement was given by Sloven or NHSE

11/
Two more bereaved parents were spoken to by @BBCMBuchanan

Mandy Park who's daughter, Hannah Groves died in 2012, aged 20 and @Richard39450952 Richard West, who's son, David, died in 2013 aged 28. A member of the trust described David's death as "like losing baggage"

12/ Screengrab from a BBC News ...Screengrab from a BBC News ...
Next day, 11 Dec 2015 @BBCMBuchanan caught up with Katrina Percy

"A failure of leadership was blamed... but Katrina Percy says she's not resigning... she went on to criticise the report's authors saying they'd not properly understood the data"

13/
bbc.co.uk/news/av/health…
This was of course a totally baseless accusation by Katrina Percy, perhaps she hadn't understood the data, after all it was big numbers, something that she clearly struggled to keep under control - more on that in a little while.

14/ BBC Reporter Michael Buchan...
Julie O'Shaughnessy's son Mark killed himself while under the care of @Southern_NHSFT The trust acknowledged they could have provided more support.

Julie wants Katrina Percy to resign

"I think watching Katrina Percy's interview, its despicable..."

15/ Screengrab from a BBC News ...
"Katrina Percy's defiant attitude today, refusing to resign, attacking the authors of the report, may have to change in the coming days.... when the full details are revealed it's hard to imagine there wont be new leadership @Southern_NHSFT"

That was @BBCMBuchanan Dec 2015

16/
In a truly breathtaking interview after the Mazars Report was published, on 17 Dec 2015, Katrina Percy said this:

"We're really sorry to anybody who loses a loved one, and its really sad whenever a loved one dies, and all of us have experienced that" bbc.co.uk/news/av/health…

17/ A woman with shoulder lengt...
She cont'd:

"and we know its a very difficult time and we're very upset and sorry to say that we might have added to that grief by not investigating appropriately... my job is to continue to lead this organisation"

Despite numerous bereaved relatives asking her to resign

18/
The Board meeting that Jezza was reflecting on earlier, was reported by @BBCMBuchanan here bbc.co.uk/news/av/health…

"Extremely inappropriate that you would even say that you might have added to our grief as a family, when you've definitely piled it on, all of you" Tom

19/ Screengrab from a BBC repor...
"The Trust told the meeting however, that no-one would resign" that was Jan 2016 bbc.co.uk/news/av/health…

April 2016 Board Chair, Mike Petter, resigned ahead of publication of damning CQC report. Katrina Percy continues to claim she's indispensable bbc.co.uk/news/av/health…

20/ Photo of Katrina Percy abov...
May 2016 and the new Chair of the Board, Tim Smart, cancelled a meeting where a vote of no confidence in the Board was expected bbc.co.uk/news/uk-englan…

June 2016 Tim Smart claimed he's conducted an extensive review, not sure how extensive given it lasted just 6 weeks

21/
He concluded that the @Southern_NHSFT executive team had been "too stretched to guarantee high quality services"... that Katrina Percy had been "too operationally focused" but he'd found no "evidence of negligence or incompetence" by any board member

22/
bbc.co.uk/news/uk-englan… Photo of Katrina Percy. Hea...
End of July 2016 @BBCMBuchanan revealed that Katrina Percy had paid millions to her associates bbc.co.uk/news/uk-englan…

"One firm received more than £5m despite winning a contract valued at less than £300,000, while another was paid more than £500,000 without bidding at all"

23/
Finally, a month later, in August 2016, Katrina Percy resigned as CEO, due to "media attention", apparently...

"Katrina Percy has finally accepted what most people concluded months ago, that her position was untenable... " reported @BBCMBuchanan

24/
bbc.co.uk/news/uk-englan…
Tim Smart created a £240k role for KP, that wasn't even advertised bbc.co.uk/news/av/uk-eng…

Months later Smart and Percy had to eventually concede defeat and resign. KP getting a £190k payout bbc.co.uk/news/uk-englan…

That's the full story, not quite as simple as suggested

/END Photo of Tim Smart who wear...

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More from @GeorgeJulian

Mar 4
There were 15 Prevention of Future Death Reports issued following inquests into deaths of autistic people in 2023.

First 5: Amarnih Lewis-Daniel 24, Benjamin Hart 25, Benjamin Hazelden 18(?), an anonymous child and Haik Nikolyan 21

[T/W Suicide]

1/16georgejulian.co.uk/2024/03/04/pre…
Amarnih died aged 24, in April 2021. She fell to her death. The jury could not be certain whether she intended to die.

Amarnih had been on a waiting list to access a gender identity clinic for over 2.5yrs at the time of her death. The coroner identified five related concerns

2/
Benjamin Hart was 25 when he died by suicide in October 2022. His care plan said he'd see a care coordinator weekly after discharge from hospital, he saw them 3 times in 6mths. He had no contact from the CMHT for 5wks before his death.

3/
Read 16 tweets
Mar 3
Here's all eleven 2023 Prevention of Future Death Reports I could find for learning disabled people.

Lugh Baker, 24, died April 2021 [Open conclusion]

David Hemmings, 71, died June 2021 [following complications of surgery as a result of an accidental fall in his home]

1/14
Owen Garnett, 19, died January 2023 [Misadventure, after swallowing paper towel while unsupervised at school. Concerns of his carers were not acted on]

Steven Duquemin, 'relatively young age', died August 2022 [accidental death, after choking on raw chicken overnight]

2/
Matthew Dale, 43, December 2020 [Misadventure in part contributed to by a missed opportunity to increase supervision to meet Matthew's needs, after he swallowed and choked on some of his incontinence pad]

Claire Twinn, 47, December 2022 [Natural causes, bronchopneumonia]

3/
Read 14 tweets
Jun 22, 2023
#LDWeek is for raising awareness and busting myths.

I present to you a dose of revolting reality.

I spent the weekend revisiting Transforming Care, and the industry around it.

Over a decade of performative scrutiny and no meaningful action or progress.

Buckle up.

1/20+
Winterbourne View Panorama was broadcast on 31 May 2011.

There was much uproar and outcry at the abuse people with a learning disability were subjected to.

An Adult Safeguarding Review was written by the ever consistently brilliant Margaret Flynn. Published August 2012

2/
You can still access it here

Flynn was unequivocal in her findings (and has been in so many reports since):

Hospitals for adults with learning disabilities and autism should not exist but they do.

3/sites.southglos.gov.uk/safeguarding/a…
Read 64 tweets
Jun 21, 2023
It's #LDWeek and your annual reminder to look behind the veneer of the largest national charity supposedly supporting learning disabled people.

@mencap_charity currently employee 207 ppl with a learning disability, a pitiful 2.5% of their workforce

1/4 https://t.co/7Bm18a4Pwzmencap.org.uk/about-us/annua…
2021: 2.5% employees with a learning disability
2020: not reported
2019: 4% employees disabled, of which 2% had a learning disability
2018: 3.6% of which 1.9%
2017: 1.4% of which 1.2%
2016: 1.7% of which 1.1%
2015: 2.7% of which 0.9%
2014: 3% of which 1.1%

Woeful

2/
It's all well and good telling the world that people with a learning disability make great employees, this from the 2020 report, the one that doesn't say how many people with a learning disability @mencap_charity employee, but if so why not employ them?

3/
Read 4 tweets
Jun 21, 2023
This has had the best legal minds on it, I'm not doubting their skill or ability, but I can't wrap my head around so much in this case and the Supreme Court's judgement. Jackie Maguire was deprived of her liberty, in a

@unitedresponse care home.

1/
If #socialcare truly had parity with healthcare I wonder if the same conclusions would be reached.

I note in the judgement learning difficulties and learning disabilities are used interchangeably, which is deeply problematic given they mean different things.

2/
Jackie, had complained of sporadic stomach pain for two months before her death [Para 68] but an ultrasound wasn't able to be performed in Dec 2016 as she was upset.

There appears to have been no further interrogation of what could have been done to change that situation.

3/
Read 20 tweets
Jun 21, 2023
This has had the best legal minds on it, I'm not doubting their skill or ability, but I can't wrap my head around so much in this case and the Supreme Court's judgement.

Jackie Maguire was deprived of her liberty, in a @unitedresponse care home.

1/
If #socialcare truly had parity with healthcare I wonder if the same conclusions would be reached.

I note in the judgement learning difficulties and learning disabilities are used interchangeably, which is deeply problematic given they mean different things.

2/
Jackie, had complained of sporadic stomach pain for two months before her death [Para 68] but an ultrasound wasn't able to be performed in Dec 2016 as she was upset.

There appears to have been no further interrogation of what could have been done to change that situation.

3/
Read 20 tweets

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