What were you doing one year ago today? I'll tell you what I did. I wrote a blog about Jesse Moores. Jesse was a vulnerable young person who died due to corporate neglect. A year ago, Barnet Council had just put up a press release
The Barnet Council press release states :-
The review criticises Barnet Council for failing to properly monitor the care that Jesse received: “The London Borough of Barnet who were paying for Jesse’s care should also have organised proper monitoring of this service since misgivings had been expressed through relatives/family meetings at which concerns had been raised about the management of, and staffing arrangements at The Chine.”My comment at the time was this
Now just remember that under the OneBarnet program the systems of monitoring will be required for everything. All services will be in the hands of private contractors. The Metpro scandal and the case of Jesse Moores show that they can't effectively monitor the existing contracts. The audit committee chairman, Lord Palmer said Barnet Council audit is chronically understaffed. The only conclusion we can draw is that Barnet Council is incapable of managing such a complex project. How many Jesse Moores do we need to prove it?
A year later many things have changed. Sadly one thing that hasn't changed is the fact that Barnet Council still doggedly refuse to admit that they are too incompetent to manage contractors properly. Let me quote you some of the official report into Jesse's death
Jesse Moores, was a young man of 26, with learning disabilities, autism and Tourettes Sydrome, living at The Chine, a residential home run by Robinia Care. He was a much loved son and brother. He also had challenging behaviour, specifically a compulsion to put objects, whether edible or inedible in his mouth. He died on 3rd Nov 2005, having choked on a ham sandwich that he had grabbed from, or been given by, another resident. It is likely that he took the sandwich to his bedroom where he died unobserved. When he was found first aid or resuscitation was not administered and there was a delay in calling an ambulance. It is unclear whether by the time he was found anything could have been done to save his life.Yesterday I attended a seminar about the One Barnet program where a series of expert speakers spoke about the problems with the way Barnet intend to work only as a commisioning council. Jesse died in 2005. The official report states that things have improved in Barnet, but it rather chillingly adds a few words about Barnet and expectations for the future.
This residential unit existed at the hub of a much wider system of commissioning, funding, assessment, care and support. His social care was the responsibility of the London Borough of Barnet. They were supposed to have a detailed contract with Robinia Care specifying the quality of care that they expected and the waythey wanted this service to address Jesse’s particular needs and challenging behaviour. In fact there was no robust or enforceable contract in place and while this may not have contributed directly to Jesse’s death it set the tone that led to an unaccountable service, operating in a cavalier way. This lack of clarity extended to the two day centres which he attended as these were not tied in to mechanisms that would haveallowed them to formally share concerns or contribute to shared risk management across all the services that Jesse used.
At the time of Jesse’s death there were serious deficiencies in the commissioning and contracting arrangements put in place bythe London Borough of Barnet and these were exacerbated by discontinuity in the provision of social work support, a failure to report concerns and incidents on the part of Robinia Care, inadequate risk management and missed reviews.
So, while there were many failings that led up to, and or had a peripheral influence on the circumstances of Jesse Moores’ death, some have been remedied and lead the panel to think that his death might be less likely to occur under the current arrangement. But with resources shrinking these improvements could easily go into reverse leaving others facing similar risks.The lesson we have to take on board from the tragic death of Jesse is that this is not all about money. Badly managed contracts in the social sector can lead to deaths. If contractors are just left to get on with it, they cut corners and vulnerable people such as Jesse die.
I wonder how many Barnet Councillors have read the official report. I would hope they all have, but if they haven't here it is. If anyone tells you this One Barnet is all simply about doing things better for less money, please remember Jesse.. He had a short life that ended tragically. When we forget the lessons he taught us, we run the risk of opening the door to more tragedies. Wherever you are Jesse, God bless you and rest in peace. As for the rest of us, lets make sure he didn't die in vain. By the 8th July 2012, we will know whether the One Barnet project was canned or not. We will know whether the Conservative Councillors learned the lesson of Jesse Moores or not. As far as I'm concerned, this document should be part of the required reading for any councillor who has any say in deciding on whether this expensive folly should go through.
Jesse Moores Enquiry