30.04.2008
This has been an exhausting day and frustrating at times when I had difficulty locating a document although this was partly my fault because I failed to created one master directory of all documents in chronological order in relation to the enquiries regarding the premature and preventable death of my care mother, who was also an aunt
It was a glorious clear blue sky morning as soon as the day rose from dawn and for once I was awake and up to see it. I was also out early for the DVD, some grapes and something for my evening meal. two pieces of slim peppered steak. I then decided it was time to attend matters which I have gradually wound myself to tackle as I knew they would involve upsetting matters and slow painstaking and at time boring activity. I started with attempting to locate the addresses and medical practices where the family had lived from 1938 and very quickly I decided to go through all the records in relation to my mother and aunt and to list the file numbers, extracting all the correspondence and documentation in relation to Parliamentary and Health Ombudsman.
Previously I had kept records according each of the separate enquiries that I was required to make instead of the all embracing which I had suggested was the only way to deal with the issue and which would be involve less and expense. I will not say that no one listened but everyone appeared to be prisoners of their system and unable or unwilling to act outside the box. The original complaints and requests to the Hospital Trust, the GP Practice, the Primary Care Trust and the Local Authority Adult community services Department was the first phase which led to the extraordinary situation of everyone blaming the other. This lasted a matter of months in which I discovered that the government was abolishing the mechanism to provide complaints with assistance and it would be sometime before a new system was available.
The second phase involved two National Health service second stage Convenor investigations but with a joint Chairman presiding, and a separate local authority enquiry, followed by local resolution meetings which usually come before the Convenor stage and which instance demonstrated the inadequacy of the Convenor investigations in this case, and perhaps more generally, as within the year they had been abolished to be replaced by a new Health Care Commission.
There were hints that there might be a helpful development on the way but no one explained what was happening and how it might assist in this particularly set of circumstances. A year had passed by and I was no closer to getting those involve to disclose what had happened or understand and accept the overall information as each group insisted on a compartmentalised approach
This commenced the third phase, which overlapped the fourth and present fifth phases. I approached the Parliamentary and Health Ombudsman for action and advice and also the Local Authority Ombudsman. I asked for a joint approach although I knew this would be rejected
I followed their respective advice and this took the greater part of 2004, involving an appeal back to the Health Convenors and an second stage inquiry by the local authority. I seriously considered approaching coroner but having decided against this the previous year, my reasons for not doing so remained so.
Following the refusal of the Convenor Chairman who reconsider the position I went back to the Health Ombudsman as advised and was put in a queue, such is the volume of complaints, and then I received a better but still unsatisfactory report from the local authority where the option was to press for another level but still separate enquiry. I decided to reconsider the position and concluded there was little prospect of getting those involved to reappraise their positions or examine the collective information that was then available. I was preparing to move homes, was unhappy with the day to day care my mother appeared to receiving on my monthly visits of a week and although it was less expensive and more convenient to keep her flat going than hotel accommodation, it was a drain on savings to continue to do so. Once I had taken the decision to move her I also lost my base from which to maintain direct contact with everyone involved with the complaints and if I was successful in getting one enquiry it would be beyond my means pay for legal representation, or acquire the temporary accommodation to represent myself, and it would also involve going back to having less contact from what were at that time seven visit's a fortnight
The decision was to concentrate on getting appropriate official bodies and interests to investigate what had happened on the basis of the effective implementation of changes to systems and approaches which had been mentioned by some of the parties involved, and to get external confirmation that the changes were appropriate, were then implemented and their effectiveness monitored. This might be considered a standard response, given the plethora of monitoring systems that there are for the health and welfare services, but it is not the situation and is why I have never been a enthusiast for those inquiries which concentrate on general issues and make general recommendations which are either not implemented or the effectiveness monitored and adjustments made if they are.
I made contact with appropriate bodies and interests, learnt of the changes in the Health Complaint and Inspection system which had occurred but which I, and everyone else who were caught up in the previous system had missed out of. By early 2005, that is two years since the death of care mother it was evident that nothing to progress the situations was going to happen and I resigned myself that that I ahd gone as far as I could and would attend to my work as well as preparing for a move of home myself. There had also been a development which affected me greatly as my mother had nearly died having contracted a bad chest infection which I made a pre Christmas visit to London for three nights. When she recovered I decided to visit every day and to limit my visits away from the area. I had decided to explore further family history in relation to my mother having gone as far as seemed appropriate in relation to my father during my mother's remaining lifetime.
Then I heard from the Parliamentary and Health Ombudsman that the required two separate investigations would be proceedings during the year so. Given the stress and time that had been involved I put everything to one side to await the action of others and then as the summer progressed I was able to sell the former family home and finding an ideal alternative property in one of the neighbourhoods and I had considered the best available for my changed situation. Unfortunately the Health Ombudsman then wrote with the proposed break down of issues coinciding with the move on homes and where all the relevant papers were among 400 boxes of documents and records from my life's work and interests. I explained the position and that I would have approached the investigation differently but had no alternative but to accept the suggested approach.
It was not until the Summer of 2006 that draft reports of the two investigations were completed when all the parties are given the opportunity to comment on matters of fact and accuracy but not on the draft findings and comments. However I decided that on the basis of what was in the two reports to provide as detailed a response as I was in a position to do so. I also assumed that the overall issues of contradictory and incompatible positions between hospital and community medical and nursing staff would be discussed if not resolved as well as my overall complaint that her death had been premature and preventable.
It was not until just before Christmas 2006 that the completed reports were submitted a Government Minister and I received my copies. They were inadequate and unacceptable. In the New Year I consulted appropriate interests and decided that the best way forward was to appeal against the findings of the Health Ombudsman and prepared a three level case. The failure to address the main issues, the failure to obtain relevant evidence or attempt to obtain evidence which could be crucial to findings that had been made and that in any event different conclusions could and should have been reached on several component issues.
The Health Ombudsman then considered the grounds for an appeal and decided it met the first of a two level appeal system. This was considered by the Ombudsman with subsequent. This took the greater part of 2006 during which time I received brief monthly notes apologising for the delay because further information as being requested from the parties involved. Then there was silence so I approached my Member of Parliament for assistance. I then heard that coincidentally the decision had been taken to move the appeal from the second to the first level. I assumed that this was good and that it was some time more. I would rather wait have a proper job done with an acceptable outcome that received something as half baked as all the previous official responses. I received monthly apologies on the basis that if the work was not completed within a month I would receive a further notice again. A month went by and one, two and three weeks have passed and no news. By any standards this is unsatisfactory and unacceptable, and becomes distressing.
I decided to at least ensure that I have all my records now in order and find that this is not as I had thought I had achieved. Previously, before moving here I had created records in relation to each agency or complaint body : The hospital and the hospital Trust. Community Nursing services and the Primary Care Trust. The General Practice services, the NHS Convenor System, the Ombudsman, the Heath Care Commission, the Department of Health, the local authority Personal Social Services Department, The Local Authority Chief Executive and other local authority services; the Local Authority Ombudsman, the second stage local authority investigation. The National Social Services Inspectorate. The Community Health Council Complaint service, the new independent Health Complaints Advisory Services; Politicians with an involvement in the specific authorities and services involved. I had prepared a summary of all events, communications and meetings from 1999 when I referred my birth and care mother to the local authority for assessment and care management on the advice of district nursing through to the second anniversary of the death of my care mother but had not dome so since. In 2006 after recovering from the house move I had reorganised my files in to three systems. The first was the complaint where I hoped I had realised one chronological record of communications, meeting and investigations reports, and other official records. A chronological record of all other papers involving my mother and aunt except for some key documentations such as the papers when in the 1950's my aunt lost the use of an eye in an industrial accident and was legally represented, receiving compensation and awarded state industrial injuries benefit which she used to buy me a new car for my 18th birthday ansd which she also subsequent used to provide subsequently financial help throughout her lifetime, The third system included all the copies that accumulated by having system for each interests together with drafts as some documents and communications were significantly revised and where the filing system on an older computer was not inadequate and I was uncertain which documents was a draft and which had been sent during 1999-2002 when I had no idea that that I would need to make complaints and have paper records as well as those on the computer. This created additional problems when one agency claimed to have lost the relevant file. Unfortunately as I went through the integrated complaint record system to extract the communications with the Health Ombudsman, I realised that I had mixed up between the two main systems and this required me to search through every folder which packs one four drawing filing cabinet and overspills to one drawer in another. Then I had difficulties with scan copier printer which led to leaving the task incomplete.
As I was leaving my house in the morning I was met my a neighbour from the opposite property in the back lane who was without water for the day due to internal works and I was able to assist with attaching a long hose to my external water tap which continued for the rest of the day until nightfall. It was good to be needed and to be able to help and went some way to compensating for the frustrations and upset from the working day.
The second episode of Cold Case had predicable outcomes but commanded attention because of the fine acting. The revealed story is of a senior officer in Basra who was failing in the set task and the protection of his men and who did a deal with a contemporary side switching Iraq Nazi who gets rid of anyone who threatens his return to power and which includes gunning down a group of women, including the child of the only one to survive and witnessed by a small band of men under his command. On their return to the UK the four men react to the action of their former superior officer in different ways with the consequence that two are assassinated, one the Cold Case and the other in front of the enquiry team. A relevant red herring is that the old school new commanding officer whose son died in a an ambush in Iraq involving the group of soldiers commits suicide during the programme also in the presence of the inquiry team. This is the problem of all form of investigation in that one ever can predict the cans of worms or the consequences, especially if one forms judgements without having all the facts and available formation to hand. I am not suggesting there has been a cover up in relation to the death of my aunt as was the situation in the Cold Case Dramas. Now am I suggesting incompetence by those investigating. This not mean that their work has been inadequate and unacceptable. One has to rely on written documentation whish even if contemporary is usually only a hurried approximation of what happened and why and then ion memory which with the passage of time can self deceive.
I was fortunate in having skilled and thorough training in case work which involved reading and continuing to read and maintain written records, the appraisal of such records, and the making of notes immediately after meetings on interviews if it was not appropriate to make notes during the meeting or interview and then to critically appraise the meeting or interview writing a much down as possible and checking existing record, This is very time consuming and requires objectivity and self awareness. I have little sympathy with police, teachers and health worker and the like whop are reportedly complaining about the amount of paper work attached to their jobs. This usually reflects an unwillingness to reappraise decisions and actions and an inability to learn from experience, including the experience of others.
A theme of the last Cold Case two parter and an underlying theme of all twelve episodes in this series is grief and guilt. It is the cause of the death of commanding officer in this episode and the cause with the team leader Trevor Eve is increasingly pushing himself go the edge as he tried to confront what has happened to the relationship with his son. Contact between them is painful and destructive, but having no contact is even more painful and destructive.
This has been an exhausting day and frustrating at times when I had difficulty locating a document although this was partly my fault because I failed to created one master directory of all documents in chronological order in relation to the enquiries regarding the premature and preventable death of my care mother, who was also an aunt
It was a glorious clear blue sky morning as soon as the day rose from dawn and for once I was awake and up to see it. I was also out early for the DVD, some grapes and something for my evening meal. two pieces of slim peppered steak. I then decided it was time to attend matters which I have gradually wound myself to tackle as I knew they would involve upsetting matters and slow painstaking and at time boring activity. I started with attempting to locate the addresses and medical practices where the family had lived from 1938 and very quickly I decided to go through all the records in relation to my mother and aunt and to list the file numbers, extracting all the correspondence and documentation in relation to Parliamentary and Health Ombudsman.
Previously I had kept records according each of the separate enquiries that I was required to make instead of the all embracing which I had suggested was the only way to deal with the issue and which would be involve less and expense. I will not say that no one listened but everyone appeared to be prisoners of their system and unable or unwilling to act outside the box. The original complaints and requests to the Hospital Trust, the GP Practice, the Primary Care Trust and the Local Authority Adult community services Department was the first phase which led to the extraordinary situation of everyone blaming the other. This lasted a matter of months in which I discovered that the government was abolishing the mechanism to provide complaints with assistance and it would be sometime before a new system was available.
The second phase involved two National Health service second stage Convenor investigations but with a joint Chairman presiding, and a separate local authority enquiry, followed by local resolution meetings which usually come before the Convenor stage and which instance demonstrated the inadequacy of the Convenor investigations in this case, and perhaps more generally, as within the year they had been abolished to be replaced by a new Health Care Commission.
There were hints that there might be a helpful development on the way but no one explained what was happening and how it might assist in this particularly set of circumstances. A year had passed by and I was no closer to getting those involve to disclose what had happened or understand and accept the overall information as each group insisted on a compartmentalised approach
This commenced the third phase, which overlapped the fourth and present fifth phases. I approached the Parliamentary and Health Ombudsman for action and advice and also the Local Authority Ombudsman. I asked for a joint approach although I knew this would be rejected
I followed their respective advice and this took the greater part of 2004, involving an appeal back to the Health Convenors and an second stage inquiry by the local authority. I seriously considered approaching coroner but having decided against this the previous year, my reasons for not doing so remained so.
Following the refusal of the Convenor Chairman who reconsider the position I went back to the Health Ombudsman as advised and was put in a queue, such is the volume of complaints, and then I received a better but still unsatisfactory report from the local authority where the option was to press for another level but still separate enquiry. I decided to reconsider the position and concluded there was little prospect of getting those involved to reappraise their positions or examine the collective information that was then available. I was preparing to move homes, was unhappy with the day to day care my mother appeared to receiving on my monthly visits of a week and although it was less expensive and more convenient to keep her flat going than hotel accommodation, it was a drain on savings to continue to do so. Once I had taken the decision to move her I also lost my base from which to maintain direct contact with everyone involved with the complaints and if I was successful in getting one enquiry it would be beyond my means pay for legal representation, or acquire the temporary accommodation to represent myself, and it would also involve going back to having less contact from what were at that time seven visit's a fortnight
The decision was to concentrate on getting appropriate official bodies and interests to investigate what had happened on the basis of the effective implementation of changes to systems and approaches which had been mentioned by some of the parties involved, and to get external confirmation that the changes were appropriate, were then implemented and their effectiveness monitored. This might be considered a standard response, given the plethora of monitoring systems that there are for the health and welfare services, but it is not the situation and is why I have never been a enthusiast for those inquiries which concentrate on general issues and make general recommendations which are either not implemented or the effectiveness monitored and adjustments made if they are.
I made contact with appropriate bodies and interests, learnt of the changes in the Health Complaint and Inspection system which had occurred but which I, and everyone else who were caught up in the previous system had missed out of. By early 2005, that is two years since the death of care mother it was evident that nothing to progress the situations was going to happen and I resigned myself that that I ahd gone as far as I could and would attend to my work as well as preparing for a move of home myself. There had also been a development which affected me greatly as my mother had nearly died having contracted a bad chest infection which I made a pre Christmas visit to London for three nights. When she recovered I decided to visit every day and to limit my visits away from the area. I had decided to explore further family history in relation to my mother having gone as far as seemed appropriate in relation to my father during my mother's remaining lifetime.
Then I heard from the Parliamentary and Health Ombudsman that the required two separate investigations would be proceedings during the year so. Given the stress and time that had been involved I put everything to one side to await the action of others and then as the summer progressed I was able to sell the former family home and finding an ideal alternative property in one of the neighbourhoods and I had considered the best available for my changed situation. Unfortunately the Health Ombudsman then wrote with the proposed break down of issues coinciding with the move on homes and where all the relevant papers were among 400 boxes of documents and records from my life's work and interests. I explained the position and that I would have approached the investigation differently but had no alternative but to accept the suggested approach.
It was not until the Summer of 2006 that draft reports of the two investigations were completed when all the parties are given the opportunity to comment on matters of fact and accuracy but not on the draft findings and comments. However I decided that on the basis of what was in the two reports to provide as detailed a response as I was in a position to do so. I also assumed that the overall issues of contradictory and incompatible positions between hospital and community medical and nursing staff would be discussed if not resolved as well as my overall complaint that her death had been premature and preventable.
It was not until just before Christmas 2006 that the completed reports were submitted a Government Minister and I received my copies. They were inadequate and unacceptable. In the New Year I consulted appropriate interests and decided that the best way forward was to appeal against the findings of the Health Ombudsman and prepared a three level case. The failure to address the main issues, the failure to obtain relevant evidence or attempt to obtain evidence which could be crucial to findings that had been made and that in any event different conclusions could and should have been reached on several component issues.
The Health Ombudsman then considered the grounds for an appeal and decided it met the first of a two level appeal system. This was considered by the Ombudsman with subsequent. This took the greater part of 2006 during which time I received brief monthly notes apologising for the delay because further information as being requested from the parties involved. Then there was silence so I approached my Member of Parliament for assistance. I then heard that coincidentally the decision had been taken to move the appeal from the second to the first level. I assumed that this was good and that it was some time more. I would rather wait have a proper job done with an acceptable outcome that received something as half baked as all the previous official responses. I received monthly apologies on the basis that if the work was not completed within a month I would receive a further notice again. A month went by and one, two and three weeks have passed and no news. By any standards this is unsatisfactory and unacceptable, and becomes distressing.
I decided to at least ensure that I have all my records now in order and find that this is not as I had thought I had achieved. Previously, before moving here I had created records in relation to each agency or complaint body : The hospital and the hospital Trust. Community Nursing services and the Primary Care Trust. The General Practice services, the NHS Convenor System, the Ombudsman, the Heath Care Commission, the Department of Health, the local authority Personal Social Services Department, The Local Authority Chief Executive and other local authority services; the Local Authority Ombudsman, the second stage local authority investigation. The National Social Services Inspectorate. The Community Health Council Complaint service, the new independent Health Complaints Advisory Services; Politicians with an involvement in the specific authorities and services involved. I had prepared a summary of all events, communications and meetings from 1999 when I referred my birth and care mother to the local authority for assessment and care management on the advice of district nursing through to the second anniversary of the death of my care mother but had not dome so since. In 2006 after recovering from the house move I had reorganised my files in to three systems. The first was the complaint where I hoped I had realised one chronological record of communications, meeting and investigations reports, and other official records. A chronological record of all other papers involving my mother and aunt except for some key documentations such as the papers when in the 1950's my aunt lost the use of an eye in an industrial accident and was legally represented, receiving compensation and awarded state industrial injuries benefit which she used to buy me a new car for my 18th birthday ansd which she also subsequent used to provide subsequently financial help throughout her lifetime, The third system included all the copies that accumulated by having system for each interests together with drafts as some documents and communications were significantly revised and where the filing system on an older computer was not inadequate and I was uncertain which documents was a draft and which had been sent during 1999-2002 when I had no idea that that I would need to make complaints and have paper records as well as those on the computer. This created additional problems when one agency claimed to have lost the relevant file. Unfortunately as I went through the integrated complaint record system to extract the communications with the Health Ombudsman, I realised that I had mixed up between the two main systems and this required me to search through every folder which packs one four drawing filing cabinet and overspills to one drawer in another. Then I had difficulties with scan copier printer which led to leaving the task incomplete.
As I was leaving my house in the morning I was met my a neighbour from the opposite property in the back lane who was without water for the day due to internal works and I was able to assist with attaching a long hose to my external water tap which continued for the rest of the day until nightfall. It was good to be needed and to be able to help and went some way to compensating for the frustrations and upset from the working day.
The second episode of Cold Case had predicable outcomes but commanded attention because of the fine acting. The revealed story is of a senior officer in Basra who was failing in the set task and the protection of his men and who did a deal with a contemporary side switching Iraq Nazi who gets rid of anyone who threatens his return to power and which includes gunning down a group of women, including the child of the only one to survive and witnessed by a small band of men under his command. On their return to the UK the four men react to the action of their former superior officer in different ways with the consequence that two are assassinated, one the Cold Case and the other in front of the enquiry team. A relevant red herring is that the old school new commanding officer whose son died in a an ambush in Iraq involving the group of soldiers commits suicide during the programme also in the presence of the inquiry team. This is the problem of all form of investigation in that one ever can predict the cans of worms or the consequences, especially if one forms judgements without having all the facts and available formation to hand. I am not suggesting there has been a cover up in relation to the death of my aunt as was the situation in the Cold Case Dramas. Now am I suggesting incompetence by those investigating. This not mean that their work has been inadequate and unacceptable. One has to rely on written documentation whish even if contemporary is usually only a hurried approximation of what happened and why and then ion memory which with the passage of time can self deceive.
I was fortunate in having skilled and thorough training in case work which involved reading and continuing to read and maintain written records, the appraisal of such records, and the making of notes immediately after meetings on interviews if it was not appropriate to make notes during the meeting or interview and then to critically appraise the meeting or interview writing a much down as possible and checking existing record, This is very time consuming and requires objectivity and self awareness. I have little sympathy with police, teachers and health worker and the like whop are reportedly complaining about the amount of paper work attached to their jobs. This usually reflects an unwillingness to reappraise decisions and actions and an inability to learn from experience, including the experience of others.
A theme of the last Cold Case two parter and an underlying theme of all twelve episodes in this series is grief and guilt. It is the cause of the death of commanding officer in this episode and the cause with the team leader Trevor Eve is increasingly pushing himself go the edge as he tried to confront what has happened to the relationship with his son. Contact between them is painful and destructive, but having no contact is even more painful and destructive.
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