CBF response to the Care Quality Commission report on progress made since the publication of 'Out of Sight- Who Cares?'
Today (9th December 2021) the report from an independent investigation into the death of Clive Treacey was published, concluding that his death was “potentially avoidable”. The report is available here: NHS England and NHS Improvement Midlands » Publications
“Our hearts will be forever broken and we will spend our lives forever missing our beautiful, kind, gentle, loving son Clive” (Michael & Pauline, Clive’s parents)
Clive was a much-loved son, brother, cousin, uncle and great uncle who was only 47 when he died in 2017 whilst in the care of a private hospital. The report sets out how, despite the determined and relentless efforts of his family throughout his life- and even after his death – the system that is meant to be there to provide support and uphold human rights, failed him.
The report author, Beverley Dawkins OBE states:
“…there are no words to describe the devastating consequences for Clive and his family and their experience of a broken system that literally swept him away.”
The report identifies “multiple, system wide failures”, including failing to listen to Clive and his family, not providing appropriate investigations of and support and treatment for health conditions, failures in commissioning which meant he was at risk of harm, an inadequate and ineffective safeguarding system and an overriding lack of good quality care, support and treatment to meet his needs. These failures continued even after his death with major flaws exposed in the post-mortem and inquest processes, and inadequacies in the investigations and complaints handling after his death.
This is another report with conclusions and learning that must be addressed – the issues exposed are not new. When will those responsible learn the lessons and will the system leaders drive the systemic change?
Support from the CBF
Family Support Service
If you have been affected by any of the issues raised in this statement, you can call the Family Support Serviceon 0300 666 0126
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An autistic man has been detained in an inpatient unit for 21 years.