Was just going to read @hsab_hampshire report into the death of Sasha Forster. Having sat thru all but a few hours of @SashaInquest last yr I feel I know the situation a little.

You can learn more about Sasha here, go get to know her but come back https://twitter.com/GeorgeJulian/status/1122434848084439045

1/

Sasha's mum @AFjustamum shared that the report had been published today https://twitter.com/AFjustamum/status/1265669184635260929

I sat imagining what it must be like for Sasha's family to still be living through their loss and the so called scrutiny of services. I clicked through to the report page

2/

Starts with a statement from @hsab_hampshire Chair; let's take a look at it:

'The Hampshire Safeguarding Adults Board (HSAB) has today published an independent Safeguarding Adults Review (SAR) into the circumstances surrounding the death in 2017 of Sasha, a young adult'

OK

3/

'Firstly, the HSAB would like to express sincere condolences to Sasha’s family for their tragic loss'

Ahhhhhhhh now. Painting Sasha's death as a tragedy is lazy. If Sasha received perfect care and she died, yes, it would be a tragedy. She received far less than perfect care.

4/

'The family has been involved throughout the review process and it is at their specific request that we have used Sasha’s real name'

Wooooowwwwww there. 'The family', wow. I think this should have read 'Sasha's family' except the tone of 'the family' says so much.

5/

'The Family were invited to provide a statement to accompany publication of the final report and this can be found at the end of this brief statement'

They've capitalised the F this time, nothing like consistency and care and attention when addressing such a situation.

6/

Also, they were invited, how blooody generous. Not we worked with Sasha's family and involved them throughout, nope, we deigned to allow them to write a statement.

We won't quote from this statement, we'll just stick it down below.

7/

'The circumstances of Sasha’s death and her history of contact with a wide range of agencies, gave rise to serious concerns'.

Now I may be super sensitive to this having sat thru @SashaInquest but anyone else read this as an undertone of it being Sasha's fault = concerns??

8/

I mean imagine, you're a young person, with complex health difficulties and you have the audacity to reach out and ask for support - and then the outright cheek to engage with a wide range of agencies, while all the time doing what you best can to stay safe. I digress.

9/

'In response, the HSAB commissioned an independently led Safeguarding Adult Review to establish any learning about the way in which local professionals and agencies worked together to safeguard Sasha'.

10/

Hmmm, presumably this independently led review will align with @sashainquest given that is the agreed circumstances of Sasha's death and recent contact with professionals and agencies. Not unreasonable to expect...

11/

'As well as highlighting some good practice, the SAR also identified important learning and key areas for further improvement'.

Please. just. STOP. This review is being conducted due to complex failings, enough of the shit sandwich, Good - Bad - Good just doesn't cut it

12/

There's no requirement to highlight perceived 'good practice'. Ever. Please stop doing this, and if you insist on doing it, stick it in an appendix. The chair choosing to highlight that while talking about 'the family' is just crass.

13/

'HSAB accepts in full the recommendations in the report and we will now be working with partner agencies to share and embed this learning within respective organisations and to deliver improvements in the key areas identified in the recommendations'

Generous of them to accept
14

'We expect the learning from this SAR to bring about positive change and improvements in':

And they list 7 areas, further highlighting why the shit sandwich approach earlier is so not cool. There is plenty that needed improvement here.

15/

Before settling in with a brew to read the SAR, I decided to read the statement from Sasha's family https://www.hampshiresab.org.uk/wp-content/uploads/Sasha-SAR-Report-Familys-Statement-21-05-20.pdf I had the privilege of getting to know them a little at @SashaInquest and they are amazing. The love and respect and care for Sasha oozed out of them.

16/

'The report is lengthy and, while we agree with some of its findings, we strongly disagree with others. In preparing this response we have not addressed every point of disagreement or factual inaccuracy. Instead, we focus on certain key issues below'

Some high/lowlights

17/

'The events on the day of Sasha’s death are not the central focus of the report and have been examined in other forums including @SashaInquest. We therefore do not address them at length here, except to make the following points regarding factual inaccuracies and omissions'

18/

a) It was common ground between the parties at Sasha’s inquest that when Sasha attended our local hospital on 31 March 2017 she did not ask to see a particular member of staff; rather she simply asked to be attended by the psychiatric team. Her request was refused.

19/

I jump to para 5.15 to see a wholly inaccurate account, that repeated states 'Sasha's parents were not happy' and to be blunt they had every right to not be happy, but they've also pointed out to you that your account is inaccurate, and it remains

20/

Sasha's family's statement continues:

'b) The extent and effect of the confusion surrounding Sasha’s crisis plan at the time of her death is not acknowledged in the report'.

21/

'The evidence @SashaInquest was that, at a Multi-Disciplinary Team Meeting on 28 March 2017 at which crisis planning was discussed, Sasha and her family were led to believe that the PLS remained an available source of
crisis support'.

22/

'The Coroner ruled that there was evidence upon which a
jury could properly find a failure in care planning which resulted in the PLS reaching a decision not to see Sasha on 31 March 2017 which was inconsistent with the care/crisis plan in place at the relevant time'.

23/

'c) It is incorrect to say that the decision not to telephone the police when Sasha absconded from another local hospital was in accordance with the inter-agency care plan'.

24/

'Again, it was common ground at Sasha’s inquest that police should have been called when Sasha absconded from the hospital (she was by that stage believed to have taken an overdose)'.

25/

Sasha's family reviewed the @hsab_hampshire report and highlighted inconsistencies and errors relating to:

> Diagnosis of EUPD
> Diagnosis of OCD
> Crisis planning
> S17 leave and the process when Sasha was AWOL
> Community-based care
> Communication with Sasha's family

26/

They end their statement with a plea for learning; it is so clear that they do not want any opportunity to help others, to be lost from their vibrant, loving, creative and sensitive daughter's life and death.

27/

Having read their statement I'm not going to bother with the official report; because if the author couldn't be bothered to incorporate their feedback, and if the Chair still refers to 'The f/Family' then it sounds like there's little point.

Almost done

28/

Sasha's family are fundraising to set up a crisis house in her memory, the sort of provision that would have made a world of difference to her life. Please share the link or donate if you can. Thank you https://uk.virginmoneygiving.com/charity-web/charity/displayCharityCampaignPage.action?charityCampaignUrl=sashasproject

/END