Category Archives: accountability

The value of a life in a care home

The Health & Safety Executive publishes a very sad story here and it is indeed a message to all those – including care providers –  who fail to understand the importance of systems, care plans, risk assessments, record-keeping, staff training and communication.  To mention but a few.

“The UK’s biggest care home provider has been ordered to pay £170,000 in fines and costs after a vulnerable resident choked to death on fish and chips during an entertainment evening at its Chorley premises.”

“The company, of Groves Road in Douglas, Isle of Man, was fined £125,000 and ordered to £45,000 towards the cost of the prosecution.”

“Our hope is that the seriousness and financial implications of this case for the company will ensure that nothing like this will ever happen again at a Four Seasons or any other care home. This would mean that Rita’s tragic death will not have been entirely in vain.”

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Thoughts on diabetics’ access to blood glucose strips being restricted

A timely reminder appeared on the BBC website today in the form of this piece bearing the title Diabetics’ access to blood glucose test strips ‘restricted’, which led me to the Diabetes UK report Access to test strips – A postcode lottery? (Aug 2013) .  The Daily Record from your short time in Care UK’s Lennox House care home featured heavily at the NMC hearings that started in February 2012 and concluded in April 2013.

One entry in the Daily Records was a strange entry, written almost as a post-script afterthought once you’d been admitted to hospital in a diabetic coma.

That entry (unsigned, by the way) gives the results of a urine test, and alongside is bracketed the following: “There was no available glucose strip since the GP does not prescribe according to Deputy Manager & Home Manager”.

Does that not appear to be a peculiar entry in a record of care?  It almost looks like an attempt to validate the absence of care.  The full urine test results were indeed alarming.  I’m not a medic but it didn’t take me long to work out which parts of the results should have rung bells.  But the care home didn’t find them sufficiently alarming to call an ambulance, because they waited  another 15 hours before doing so, by which time you were in a desperate state, with spasms lasting nearly half an hour noted hours before an ambulance was called.

When I arrived in A&E, soon after your arrival there, I was asked to explain how your diabetes had come to be ‘so out of control’.  I didn’t know that it was out of control, of course, but the hospital for some reason thought that you lived with me and that I was responsible for your care.  Not so.

When I asked the manager to explain to me what that entry in the Daily Record meant, she said that the GP refused to prescribe test strips for the care home, and that Care UK also refused to supply them.  That’s the point at which I offered to pay for a full year’s supply for the care home so that no other person would suffer the way you did.

During the investigation into what happened with your care, the investigators were told that test strips had been bought from a well-known chain of chemists – but no evidence could be found to support that.  Not even a petty cash record.

However, at the hearings at the NMC, there were other and different rationales put forward.  One proposed by the manager was that your diabetes was ‘diet controlled’ and not medication-controlled.  Not so.  When she saw you, allegedly just before she left the building, you were “warm and pink” and you gave no indication of distress, pain or suffering.  What a shame she didn’t have the time to act on your urine test result, that she was surely informed of before leaving the building.

You were not in a position to monitor your own glucose levels.  Vascular dementia made that impossible for you, and in any case your previous GP (not the one providing services to Lennox House) had monitored you regularly, as had your clinic appointment regime.  You never missed an appointment.  It was the responsibility of the care home to monitor your diabetes – that’s what care homes are supposed to do.  Care.

Another memory has been brought forward by today’s reports.  The GMC (General Medical Council) was informed by the GP involved that she had no knowledge that you had diabetes, and that had she known she would have carried out the required test and had you admitted to hospital.  The NMC was told a very different story by the nurses involved, namely that the GP had indeed been informed of your diabetes when she visited you (and prescribed an antibiotic for a suspected UTI).  They can’t all be right, can they?

Again at the NMC hearings, mention was made by the manager and other nurses and their representatives  that there had been no training in diabetes at Lennox House, before your arrival there.  It was even said that there was no specific training in diabetes given for a couple of years after your death.  Not so.  Would nurses never have heard of  Hyperosmolar Hyperglycaemic State (HHS)  (previously called  Hyperglycaemic Hyperosmolar Non-ketotic Coma (HONK) or  Diabetic Ketoacidosis  (DKA) ?

Diabetes UK calls the restricting of access to test strips a lottery.  You definitely did not win the lottery in Care UK’s Lennox House care home where your diabetes was neither monitored nor tested, whether by strip or by other means.

Barbara Young, Diabetes UK Chief Executive,  said “Rationing test strips to save money does not make any sense, because  it is putting people at increased risk of complications that are hugely expensive to treat.”

You’d be a fool to argue with that.

I sincerely hope that Home Secretary Theresa May, recently diagnosed with diabetes, will not find her access restricted.  If she does have that experience, she will no doubt take steps to ensure the restrictions are lifted.

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Care UK regrets they weren’t able to care for you, madam

With apologies and thanks to Cole Porter and Ella Fitzgerald, two of your favourites.

Care UK regrets they weren’t able to care for you, madam.

Care UK regrets they weren’t able to care for you.

They can’t even apologise.

Best they can do is  just general regret, madam.

Care UK regrets they weren’t able to care for you.

Care UK strives to provide appropriate care for all their residents across the various services that they run.”  Allegedly.

It is always a matter of regret if a service is not provided as they would wish.”   Allegedly.

Apparently I “clearly consider that there were failings in the care provided” to you.  I most certainly do, and I’m not alone in that opinion.

Care UK’s solicitor has been asked “to pass on their regret in respect of this”.

Care UK has been made aware of the fact that Catherine Igbokwe and Sheila Ali have both been struck off the register by the NMC (Nursing and Midwifery Council) for misconduct and for failing you miserably, and that Maria Rholyn Secuya (nee Baquerfo) has received a 3 year caution order for misconduct and for failing you miserably, and that Dahlia Dela Cerna (nee Enriquez) has received a 2 year caution order for misconduct and for failing you miserably.

Care UK can only  come up with an expression of general regret, via a third party at that.  General regret is overworked these days.

Care UK promised to provide a substantial sum in your memory, acknowledging that it failed miserably to provide care to you, and so that we would be able to establish what Care UK’s then Managing Director of Residential Care called “a positive contribution to the world of dementia”. In your memory.   Care UK has now broken that promise.  How foolish we were to place our trust in Care UK.

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Care Circus is back in town next week

Well, here we go again.

Next week the Care Circus is back in town.

The latest batch of NMC hearings is about to stir its loins again and get on with the work that it was charged with handling long ago on 1 October 2008.  That was only a few very short months after you died, thanks to the rubbish care that came your way, courtesy of Care UK and Lennox House so-called care home in Islington, London.

It was also a few very short months after I’d asked so many questions of Islington’s Mental Health Care of Older People team, and then Islington’s Social Services, and then the CQC (or CSCI as it was called back at the beginning of 2008), and the Coroner’s Office, and Islington’s Safeguarding of Vulnerable Adults Team, and  most of all of Care UK … well, you will know how many questions I asked of them all, each and every one of them.

They don’t like answering questions, do they?  Especially if those demanding but necessary questions are likely to cast a very dim and dark shadow over their (lack of) accomplishments.

Last December 2012, the NMC decided that one nurse involved in your demise should be struck off, from their register of nurses allowed to nurse in the UK.  Another nurse was delivered a 3 year caution order, requiring her to be on her best behaviour.

Next week, 15 to 19 April 2013,  the Circus is back in town.  Fifteen months after the NMC hearings first started, looking in depth at the circumstances surrounding your rapid decline, within 10 days of arrival in that so-called care home, Lennox House, and your admission to hospital in a diabetic coma.  You died 3 weeks later.

The  final 2 cases, still waiting in the wings, are to be dealt with by the NMC next week.

One case  is that of the care home manager, who is mid-way through an interim 9 months suspension order, placed to allow time for her to seek permission for a Judicial Review in the High Court, of the NMC decisions thus far.  The High Court refused permission to seek a Judicial Review.

The clowns will all be wearing their costumes.  Their faces will all be heavily disguised beneath the cake of their make-up.  They will all have their props to support them.  Their scripts will all have been written, re-written and then written again.  Edited, heavily edited, and then edited again.

You weren’t allowed to write a script of  your own, were you?  Let alone edit it.

The script of your final years, months and weeks of your life was snatched from you.  Grabbed by thugs.  The uncaring, unqualified, untrained, unmonitored, unsupervised, unsuitable thugs who were charged with the most basic and fairly simple duty of looking after you.

Next week, they will still be wearing their masks, their costumes  and their heavy make-up.

As they will continue to do year after year.  Uncaring as always.  Unkind in their presentation thus far.  Unwilling to admit that they failed miserably in their duty of care to you, for you and about you.  They didn’t care enough to care.

The chance to wear your dresses, your gentle make-up and to present your smiling face to the world was taken from you.  By the thugs of care.  The thieves of care.  The robbers of care.

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Alzheimer’s Society and the Horse fraternity

Over recent months or even years, many people have become irritated, bemused, frustrated, confused and perplexed by the Alzheimer’s Society’s online chat room also known as Talking Point.  Posts have been dumbed down and members dumbfounded by many of the decisions made by the appointed representatives of the Alzheimer’s Society, working and operating its online forum.

Many people were hoping that things had changed, once the Alzheimer’s Society had rid itself of what it perceived to be irritating members who were brave enough to challenge the Administrative nonsense going on.  Similar to the way that Julie  Bailey and ‘Cure the NHS’ have challenged the brick walls of care, resulting at long last in the Francis Report.

It is so easy for the Alz Soc to ban forum members who challenged the ignorant actions of its Administrators and Moderators.  The Alz Soc compromised many members by editing and/or deleting their posts, even if they only referred to Winterbourne View, or … wait for it …. the British Geriatric Society, or even Peter Carter of the RCN.  All mentions were obliterated without being able to be questioned by the members.   Members who posted about BSE or CJD and dementia-linked situations were also deleted and obliterated.

It was all too uncomfortable for the Alzheimer’s Society to contemplate such matters.

It is far too comfortable for the Alzheimer’s Society to silence those members who had the guts to challenge matters.

It makes  me wonder how the Alz Soc will react if/when the latest horse-meat scandal comes to evidence a connection between dementia and the introduction into the human food supply of a drug called Phenylbutazone – a drug that is now only used in the care of horses but which was  previously used in the care of human beings who also happened to have arthritic/rheumatic joint problems.  The experimental use of Phenylbutazone in humans was disastrous and resulted in death, and it also resulted in Phenylbutazone being banned for use in human beings suffering from arthritis/rheumatism.  That was circa 1975, so it’s possible that any use of Phenylbutazone now in human beings is heavily restricted, controlled and monitored.  I hope so.

The Alz Soc shed the skin of those that it felt irritated by, namely those who posted examples of sub-standard care.  All mention of Winterbourne View was eradicated from the forum, as were posts mentioning Southern Cross, to name but a few.

Almost overnight, it became acceptable for people to name Stafford Hospital, to call social services ‘social circuses’, to talk of ‘lies and more lies’ when referring to social care systems that the posters had come by.  Even mention of MPs was suddenly allowed, whereas previous posts mentioning similar had been edited and/or deleted.  So members were thinking that things may be changing and on the up.

The forum Administrators and Moderators prod and poke and provoke.  Until such time as the Alzheimers’s Society’s appointed Administrators and Moderators can ban thinking members.  It’s so much more comfortable for the Alz Soc to leave its own comfort zone untouched and unsullied by those Members of the Alz Soc who would like questions to be answered.

The latest example goes beyond the acceptable when it comes to caring about dementia.  [I choose not to use the word Alzheimer’s because it denies recognition of all other forms of dementia.  It also sweeps away most of the important factor that people living in the UK care about at present.]

It is all swept away by someone who has no idea what it means to be trying to achieve quality care in the UK.

Here, the Alzheimer’s Society’s online Talking Point forum:

“While this may be your view, that’s all it is – your view. Some care homes may be like this, some are not. To state that all of anything is untrustworthy is inappropriate in my view.”

Is that the view of the Alzheimer’s Society?  Is it the view of an appointed Alzheimer’s Society person?  Is that the point of view of someone who has not one single clue about what it means to be living in the UK with dementia and caring about those who are living in the UK with dementia, let alone those who are living in the UK and still dealing with the care home system that is so sadly lacking in quality and standards of care.

It is the point of view of someone – an online forum Moderator,  appointed by the Alzheimer’s Society –  who has never had any direct experience of the care home system in the UK, who has never had any experience of social services in the UK, who has never had any dealings with that which most people are dealing with when it comes to care in the UK.

But someone who  is still given full reign to spout about that which affects every single person living in the UK.

A virtual Queen of the World.

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Care in the UK – 5 years on – Part 3

This day five years ago, 31 December 2007, was a difficult one for many reasons.  I know that you won’t wish me to go into the detail of some of those reasons here.

We drove to London again and spent 4 hours at the Whittington Hospital dealing with various formalities. Most of the morning we spent in the PALS office (Patient Advice and Liaison Service) and talking on the phone with the Coroner’s Office and with one of the hospital doctors involved in your care.  We grabbed a coffee and  left at about 1 o’clock, having decided that we did not want to have to return to that part of London again in the near future.

That’s why we went – on the spur of the moment, unplanned and unannounced – to Lennox House to collect your belongings and avoid the need to go back there again.  While you were still alive, just, I’d already asked the manager to send me a copy of everything on your records.   On 20 December 2007 I received a copy of a document that Care UK calls the ‘Daily Record’ .  It was only 9 pages so I asked the manager to copy and send everything else.  It was the only document I’d seen then, but it gave a good indication of the very days when you must have been desperate for help, but no indication of any help being given.

We parked the car and were able to walk straight into Lennox House.  So much for security.  The manager was at reception, but she didn’t recognise us.  She’d only met us once before,  back in August 2007 when we went on a recce to Lennox House, just one of the care homes we looked at.  There was no reason she should have recognised us.  I introduced myself and explained that we’d come to collect your belongings.  She said she’d just been speaking with your niece on the phone and she was planning to collect your things.  It was easier for us to do it there and then, as that niece doesn’t drive.  She also said that she was just writing a note to me, to accompany the paperwork I had asked for.  I said I’d take it all with me and save her the trouble of posting it.

We went to your room, and packed your things; a few were missing, especially two rings.  I asked for them – but I was assured you had not had any rings on your fingers when you arrived in Lennox House.  It was an uncomfortable thing to hear, because we ‘d bought one of those rings, the ruby ring, for your 80th birthday.  The sapphire and diamond ring had been on your finger for the last 60 years –  more years than I care to remember.  I’d noticed you were wearing both rings when we last saw you there, in November.  Eventually, the staff managed to come up with one of the rings.  The other one never surfaced.

We went down to reception.  I was asked to go into the manager’s office, while “His Lordship” as you always called him took your things to the car, before returning.  In that office, I was subjected to an inquisition.  I was expected to go through every single line of the Daily Record and explain my concerns to the manager, as she wrote alterations on the pages.  I thought I’d already done that on the phone earlier in December, but I still had to go through it all again.  It became impossible for me, and I left the office in tears saying I just couldn’t go on with it.  We had spent 4 hours at the Whittington Hospital, and I was exhausted.

I told the manager much of what we’d been through when you were in hospital, including being asked to explain how your diabetes was so out of control.  I’d already spoken with the GP who hadn’t bothered to look at the meds you were taking, when she’d been called to the home, and who told me she was not aware that you were a diabetic.  If she had been given a list of the meds you were taking it would have been obvious to her that you were a diabetic.  If one of the nurses had told the GP you were a diabetic, she might have treated you differently.   (She’d never met you before, as you were new to the care home and new to the surgery providing services to that care home.)  Interestingly, it was only from that Daily Record that I discovered the GP had spoken with Lennox House (on 14 December 2007, while you were in hospital) before she returned my call to her that day.

The manager told me that there were no available glucose strips in that home,  because the GP does not prescribe them.  The manager told me that Care UK wouldn’t provide them either.  To say that I was shocked, again, would be an understatement.  I volunteered to pay for a year’s supply so that no other person with diabetes would ever arrive in A&E in a diabetic coma, like you did.  With much of your bloods and tests ‘deranged’ .

I’m still trying to work out why those same words about glucose strips being unavailable are written in your care home notes, in the Daily Record for 7 December 2007.  It’s such a strange few lines to have been added to someone’s personal care record.  After all, you weren’t the only resident with diabetes, so  it strikes me as a very strange addition to your records.  Contemporaneous?  I doubt it.

The manager said “we have taken steps to make sure this never happens again”.

That was too late for you.  You only had one chance.

What I didn’t know until much later (namely July 2008)  was that a ‘Complaints Form’ came into being on this day, five years ago.  Its purpose was to indicate that ‘a meeting had been arranged’ to discuss my concerns, all of which appear to have been resolved that very day.  I learned from CSCI (Commission for Social Care Inspection) that a ‘meeting had been arranged’ this day, 5 years ago, to discuss my concerns.   It must be the first ‘meeting’ where people stood to ‘discuss’, rather than sat comfortably.   CSCI asked for a copy of the minutes of that meeting.  CSCI is now the CQC (Care Quality Commission).  There were no minutes – because it was not a meeting.  It was a chance encounter.   (More about this all another time.)

I left Lennox House in tears.  This day 5 years ago.

You deserved better care.

(To be continued)

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Nadine Dorries & her super-inflated ego

I haven’t been bothered to keep up with Nadine Dorries and her antics until now.  Partly because I don’t often watch that programme.

I’ve heard the rubbish that she has occasionally spouted, and I’ve read the rubbish she’s reported as having spouted.

All I can say is Get Her Out of Here.

She appears to me to be just another self-centred, fame-seeking, super-inflated egotistical mind-numbingly boring person who does not deserve to be supported by the Public Purse.

 

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The liars who pretend to care in the UK

Will the liars who pretend to care be able to hold their heads high?  Meaning that if – or even when – they have fatcat liars to tell lies on their behalf, what chance does the decently honest person have against the might of their lies?  Especially if the ‘system’ in place is geared to work against the decently honest persons telling the truth, the whole truth and nothing but the truth.

The liars are not required to speak much.  They have a pre-written script to follow, worked out by their fatcat liars-on-behalf.  Half-liars both of them = one almighty fat liar.  Both full liars = 2 almighty fat liars.  Multiply that by 3 or 4 or 5 or 6, and you have a system that stinks.  But it’s the way that care in the UK has decided to go.  Down the drain.

Will they be able to sleep at night, or even by day?  Hopefully not.  Forever and a day and a night; forever and all days and all nights.  Hopefully not.

Will the person who tells the truth be able to sleep at night, or even by day?  Probably not, but only because they may be destroyed by the lies they are not allowed to challenge.  They are now voiceless against the lies, not sure of what they are dealing with, not sure of how on earth this could have come about.

But knowing still, that they have done all they could possibly  do to present the truth, the whole truth and nothing but the truth.  All single-handedly; all honestly; all openly; all transparently.

Does the truth no longer count?  Do lies count more in our sadly sickeningly careless world?

Who cares?  I do.

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Why I despise the so-called system of care for vulnerable people

I’ve been fairly controlled over recent weeks, months or even years.  I suppose I’ve been waiting and hoping for a chink of light to emerge, for a culture change to emerge, for a way forward to emerge in the so-called system of care that we have allowed to be in place.

However, I am reaching screaming point.  Hardly surprising.  When someone is destroyed because of absent systems of protection, and when it then takes almost 5 years to work your way through to a full understanding of why the so-callled system of care for vulnerable people fails to provide decent care so very often – that’s when you reach screaming point.

Time and time again, the CQC comes up with yet another report as it did today, with a report into the ‘care’ afforded to people with learning disabilities.  Or rather the lack of  care.  I’ve read it all, but there’s not much hope for real change.

Week and month after week and month, our government comes up with …… not one single plan to improve things.

Year after year, the same old same old same old gets published in the press, reported on radio, featured on TV.

Still nothing changes, so I need to scream now.  It won’t change anything – but it may just help me to scream.

[Next section of this particular blog post: Deleted temporarily pending the return of sense to the world of care.]

Therewith, I will leave this one for today.  But not for long.

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To care or not to care?

Imagine the 83-year old person in the following story was your own relative.

The article is here : Islington Gazette – dated 10 February 2012 – a few extracts below:

‘The Nursing and Midwifery Council’s (NMC) Conduct and Competence Panel is investigating five nurses’ care and treatment of an 83-year-old woman who died after spending around 10 days 
at Lennox House Nursing Home in Durham Road, Islington.

The panel heard this week that the elderly woman was taken to Accident and Emergency at Whittington Hospital in a diabetic coma on December 8, 2007. She died on December 27.

It is alleged that several serious signs of deterioration in the two days leading up to her hospital admission weren’t acted on.

These included agitation and a tendency to lay on the floor – symptoms which retired nurse Sue Bradell-Smith, who carried out the investigation of Lennox House in 2008, said were abnormal and would have made her “very worried”.

Other allegations include a failure to monitor the patient’s condition and diabetes, failing to create a pain management plan and feeding the patient fluids orally although her swallowing difficulties were known.

According to the home’s records, by the evening of December 8 she was suffering with continuous muscle spasms and had dysphasia, an inability to speak – yet it is claimed that the emergency services weren’t called straight away.

NMC’s solicitor John Lucarotti said the treatment provided fell far below what is expected of a nurse.’

How would you feel if you are now being required to understand alleged facts that are totally new to you – almost four-and-a-half years after the death of your relative?

You are now being given to understand that the care home manager was in the building all day long, right through from 8.30 am to 8 pm in the evening – but couldn’t be bothered to get off her backside to attend to one 83- year old in desperate need of care and attention.

You are now being given to understand that a nurse came to see the manager and told her that the 83-year old was not well.  Still the manager did nothing.

You are now being given to understand that nobody involved considers that the care they provided was poor.

You are now being given to understand that the manager didn’t react or even care much when the nurse told her the 83-year old was in spasm, unable to speak, unable to swallow.

Can you imagine how you would be feeling now?

 

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