#LessonsUnlearned

A Norfolk Adult Safeguarding Board report has reported on the deaths of Joanna, “Jon” and Ben (all in their 30s), who had learning disabilities and had been patients at Cawston Park Hospital. I wrote about Ben King here. The political debate about the future of social care has been almost entirely about money, but there is no lack of money problem here: Care of the kind these much-loved young adults received can cost £12,000 per week. As government care inspectors CQC have set out, there are nearly always community or home based alternatives, and these are invariably lower cost (Shared Lives is on average £30,000 per year lower cost, and CQC says it is 96% good/outstanding).

The Safeguarding Board sets out lessons and learning, including what professionals should do (ask more questions, be more ‘curious’, challenge more), giving people ‘meaningful occupations’, paying attention to physical health. The fact that these things need to be recommended, says that there is something deeper going on than a few ‘bad apples’. Until quite recently, racism was talked about by the media and politicians almost entirely in terms of individual behaviour. The reality that racism is structural and built deliberately into systems is still one which many white people, who often benefit from those systems, are reluctant to accept. We need to think about the oppression of people with learning disabilities in the same way. The ‘lessons learned’ from these abuse or neglect scandals are always the same. We need to start calling them Lessons Unlearned, and asking ourselves why we refuse to learn them. The lessons and learning from the Norfolk report include none of these:

  • This support system structurally oppresses disabled people.
  • This support system is designed to give non-disabled people a powerful voice, and disabled people and their families no voice, except for tightly-prescribed opportunities to talk on terms entirely decided by others.
  • The in-built risks of these kinds of services make them unacceptable in a modern society, and they must close.
  • Alternative services can only safely be designed by disabled people and their families.

No system or bureaucracy has a self-destruct policy, so no matter how badly it fails, it will always recommend improving itself, not replacing itself. The non-existence of a part of the public service system shouldn’t be more unthinkable than the end of a human being’s life, but these reports always start with the assumption that it is. The lessons are always the same, because what can never be learned is: we have to cease to exist for people to be safe.

Something pointed out to me by Philipa Bragman and demonstrated on a daily basis by the leaders with learning disabilities who worked (were employed, not volunteered) at CHANGE is that people with learning disabilities are the only oppressed group who are systematically excluded from what should be their own civil rights movement. As long as those of us who work in the public service sector continue to try to learn lessons on behalf of a group who are harmed and killed by a set of public services with what should be terrifying regulatory, they will remain lessons unlearned.

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