Buster Lewin

It is a bad road when ice/snow conditions are in play. It makes sense to avoid it when these conditions are occurring, as there are sections unless your on the right rubber, you wont have control of the car, regardless of how good a driver you are. If i was using the Mountain Road to commute, then i would certainly have a spare set of rims with winter/snow tyres on, the difference is like the Formula 1 cars trying to use slicks in the rain. It is totally amazing the significant increase in traction that you have when you have winter/snow tyres on, even over ice patches. In European Countries where there roads that are dangerous when snow or ice is present, then by Law you can only travel on these roads with winter/snow tyres on. As there are at lease two other significantly safer routes available to motorists, then why take the risk of accident/personal injury to yourself or a third party.

This matter has become so complex now, that one of the big 4 accountancy practices should be commissioned to investigate and record the facts and identify to whom and how fees are paid together with salary costs as they relate to the IOM investment. I said it from the beginning that once you become involved with these major companies, the Island doesn't have the know how to ensure how monies are managed, and I do honestly believe not that Eddie Teare is now certainly out of his depth, that's the reason he is giving arrogant answers, as his pride will not allow him to tell us that he doesn't understand or lost control of how the investment is being managed from the start to the end. He needs to be honest to himself even, and put up his hands and ask for help.

At least Alan Bell has admitted Mental Health Care is abysmal, then with respect I would ask him to ensure that the Public Inquiry that Juan Watterson is now going to carry, it is an overarching Inquiry that includes the Prison, in order to ascertain why people with mental health illness are regulary being put in Prison, where there is no adequate specialist mental health treatment available to the person. Not to put words in the Chief Ministers mouth, he may describe the operation of the Prison as being "inhuman and degrading". But that would be for an Independent Public Inquiry with an independent Chairman from the UK so no stone is left unturned to conclude.

As to Johns comments, regarding making the unit comfortable, then I have copied an extract from the Coroners Report which is:- I also fail to see how the magnetic type would be perceived as "too institutional". I am not saying that Mr Harrington deliberately invented that evidence. It just appears to me that he is probably mistaken and I cannot rely upon it. Buster, you are just out of prison for, (I think) fraud, deception and god only knows what else, yet you have turned up on MF posting as if you are some sort of authority on all subjects and whiter than white. I wonder how many other people think you are a bit out of line judging others? John, it is dangerous to "think", my replies to your statements were from extracts of the Learned Coroner, it serves nothing to spit out your dummy at me, surely you are not saying the Learned Coroner is not whiter than white are you. By the way you still haven't set out what your professional involvement with Grinagh Court, I wonder why?

John, your opinion is not supported by the UK NHS Estates Alert Notice as far back as November 2004, some ten years ago, and further back to 2000 when the said Notice was sent to the Chief Executive of the Islands DHSS at that time, but the Coroner found "was not acted upon by either Mental Health Services or Estates. That alert notice reminds staff of the report of the UK's Chief Medical Officer of 2000, referred to already, regarding the need to remove all non-collapsible shower curtain rails in psychiatric inpatient settings and replace them with collapsible type rails. UK NHS Estates Alert Notice reference number 'NHSE (2004) 10' of 16th November 2004 which appears to have been sent to the Chief Executive of the Island's DHSS at the time, was not acted upon by either Mental Health Services or Estates. That alert notice reminds staff of the report of the UK's Chief Medical Officer of 2000, referred to already, regarding the need to remove all non-collapsible shower curtain rails in psychiatric inpatient settings and replace them with collapsible type rails" With your legal expertise, should not the person or persons who failed to act on this advice, now at least be subject to a criminal charge, which would then allow a jury to find if the person or persons are guilty or not as the case maybe of a criminal charge?

Had the Dept been made aware of the dangers of non collapsible shower curtain rails, I have copied out an extract from the Coroners Report:- 112. One particular feature that was a cause of concern in this case related to the fact that the UK NHS Estates Alert Notice reference number 'NHSE (2004) 10' of 16th November 2004 which appears to have been sent to the Chief Executive of the Island's DHSS at the time, was not acted upon by either Mental Health Services or Estates. That alert notice reminds staff of the report of the UK's Chief Medical Officer of 2000, referred to already, regarding the need to remove all non-collapsible shower curtain rails in psychiatric inpatient settings and replace them with collapsible type rails. Yesterday I heard the evidence of Miss Barbara O'Leary who had been the Health and Safety adviser for the Department since 2002. Miss O'Leary indicated that the system in place by which the Department dealt with such alerts in 2004 was that the alerts in paper form were received by an administrative officer in the Chief Executive's office and that officer then sent all alerts out directly to the relevant frontline service departments. Miss O'Leary pointed out that it had not been her role to coordinate or implement such alerts. Mrs Notman could not remember receiving NHSE (2004) 10. None of the witnesses who had worked for Estates could remember having seen that alert. It appears to have been accepted by the Department that the advice at paragraph 5 of NHSE (2004) 10, specific to ensuring regular maintenance checks and load tests were carried out according to manufacturers' instructions of collapsible rails, was not acted upon because the alerts did not reach the appropriate personnel. I find is a fact that this is the case and as such it amounts to a systemic failure. 113. As to what had changed since the incident involving Ben, Miss O'Leary indicated that Mental Health Services and Estates have now designated people who signed up to the electronic central alerting system operated by UK NHS. However to Miss O'Leary's knowledge there was no auditing of these services to ensure that the content of such alerts had been properly acted upon with the exception of Primary Care.

As to Johns comments, regarding making the unit comfortable, then I have copied an extract from the Coroners Report which is:- I also fail to see how the magnetic type would be perceived as "too institutional". I am not saying that Mr Harrington deliberately invented that evidence. It just appears to me that he is probably mistaken and I cannot rely upon it.

I have set out below am extract from the Coroners Report:- 129. In summary, having taken all matters into consideration I answer the following necessary questions regarding whether the test for neglect has been satisfied as follows: a. Was there a failure in connection with basic medical attention or care (including the provision of basic and obvious safety features for acute mentally ill patients who have a recognised risk of suicide and may act impulsively)? The answer I have reached is yes there was a failure to provide collapsible shower curtain rails. b. Was that a substantial failure (not a trivial one)? Because of the known level of risk from non collapsible curtains, the consequences of the risk involved being in all likelihood a fatality, and the ease with which the risk could have been alleviated by the provision of properly designed collapsible rails, I conclude this was a substantial not trivial failure of systems. c. If the basic medical care had been provided in the obvious and basic way expected was it more likely than not that Ben would not have died as he did? My answer is again in the affirmative. 130. I am of the view that the lack of provision of a collapsible shower curtain rail in Room 10 on 12 June 2012 was a gross failure in the basic care provided to Ben such that his death by suicide was contributed to by neglect. I shall, though, record my verdict in narrative form.

There can be nothing more unfortunate than a person losing his life in a place which in this is there to prevent such loss. Surely common sense would have noted the shower rails, and is there not in place a requirment for regular health and safety reviwes to be carried out, to identify areas of potential risk, and then for action to be taken to reduce the risk. If there is not, then is very clearly a very serious breach of what would be expected of ensuring such a place is free from risk for in particular patients who are of the mind to take their own life. I would trust that the Health and Safety Inspecorate were called in immediately after the incident, and that their recomendations are made public. Surelly where a loss of life has occured, that the police would be called in to investigate if any criminal breaches may have occured. Do we know if Prosecutions are now going to be brought. As to the wiping of computer records, then this had to be done with intent, again will a prosecution be brought now?