Thread 1/12

Somehow managed to finish reading the review into the Leder review into Oliver McGowan's death last night. It's here if anyone would like to https://www.england.nhs.uk/wp-content/uploads/2020/10/Independent-Review-into-Thomas-Oliver-McGowans-LeDeR-Process-phase-two-_20-October-2020.pdf

So much so wrong but I wanted to focus a minute on the role of the @mencap_charity family advocate

Much of the review of Oliver's Leder process pivots around a multi-agency review meeting held in June 2018 with an independent chair (with no knowledge of Leder or MAR process) and attended by various relevant organisations, who played a role in Oliver's life and death 2/12

For some unexplained reason Oliver's parents were invited to the first 2hrs of meeting with the MAR panel. Then after they left the meeting, a number of providers were invited to join and the conversation continued. A @mencap_charity family advocate was present throughout 3/12

I'm not a trained advocate, but I have worked as a family representative on a number of NHSE death investigations. It is not an easy role. For me it means I am there first and foremost for the bereaved family, I am there to ensure they are not forgotten and they get answers 4/12

At times this is difficult. You have to speak up and potentially say any number of things that make others in the room feel uncomfortable. Often you have to challenge the status quo, language, assumptions and biases about learning disability. That's what you're there for 5/12

You're not there as a fly on the wall; you're not there so that everyone 'feels' like the family are included, you're there solely to ensure that they are. That their views are considered, and the questions they need answered are (as far as is humanly possible) answered 6/12

I was particularly interested in the @mencap_charity advocate. Paula has always staunchly defended Mencap, even in the face of blatant failures in their care and traumatisation of other bereaved families by them. I assumed that they at least had a good experience themselves 7/12

Turns out there is no clarity over whether Question 8 'Was the death potentially avoidable?' was discussed at the MAR meeting. Having read the background to this meeting, as the advocate this was the most important question to get answered for the family 8/12

The advocate states the question was not asked but it was 'just obvious that it was potentially avoidable'...

My view is that you can't make such assumptions. They have to be agreed, spoken about and recorded, however uncomfortable or irritated it makes people 9/12

They go on to say 'I realised the chair had not specifically asked this question but felt it had been talked about at the meeting enough for it to be very clear'

What is the point of an advocate who knows a question hasn't been asked, and doesn't ask it? 10/12

Later they refer to the 'difficult discussion'... I think difficult discussions are the bread and butter of advocacy.

I feel for Oliver's parents, for that advocate (despite their ineffectiveness) and for the lead reviewer MsA who was under pressure from all directions 11/12

Where I come back to tho, is there are too many meetings, too many words, too much performance, and not enough actual scrutiny.

Leder is IMO a pointless distraction, gathering opinions but not fact, reviewing but not investigating. And still people die decades prematurely /END