Freedom of Information

The following FOI request was sent to NHS England on 22 December 2015. It is reformatted, slightly redacted for  brevity and contains a minor change to the return email address for consistency with this web site.

Questions 1 – 3 are posed because there are several organisations at the same address. Will publish response in due course.

“To: england.contactus@nhs.net <england.contactus@nhs.net>

Subject: Freedom of Information

Dear Sirs

I refer to the recent meeting between Oxfordshire Council and NHS England at Jubilee House and the photographs allegedly taken of peaceful supporters of Dr Sarah Ryan. Please see: 

https://mydaftlife.wordpress.com/2015/12/18/mazars-the-pop-up-display-and-lives/

I assume that this is the Jubilee House at 5510 John Smith Drive, Oxford, OX4 2LH – one of your area offices.

Pursuant to The Freedom of Information Act 2000 (as amended), please disclose the following information.

1. Is this the correct location?

2. If not, where did the meeting take place?

3. What organisation arranged the surveillance?

4. Who specifically (by name or job title) authorised the surveillance?

5. Who is Data Controller of the images?

6. Who owns copyright to the images?

7. What was the purpose of photographing the supporters? Clearly, it was not to prevent a breach of the peace and, had there been serious issues of trespass, the police should have been called.

8. Have the photographs been destroyed?

9. Has the photographer retained copies of the images?

10. Have the photographs been shared by the Data Controller with any other organisations?

11. Other that the photography, were any other means of surveillance being used?

This information is requested because:

i) It is the public interest to know when (and for what purpose) the NHS is carrying out surveillance when there is no obvious reason to do so.

ii) The data subjects (i.e. those appearing in the images) are entitled to know who is Data Controller.

This application being made outwith normal working hours, I look forward to hearing from you by the 20th working day from tomorrow’s date, 23rd December 2015.

I look forward to hearing from you. Please note that the email address to be published is:

crash@marchwood.free-online.co.uk

Yours etc.

Mob: (+44) 7729 662394″

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Open letter to Chairman

[Author’s details redacted for online purposes only]

OPEN LETTER                                                                              22 December 2015

[Southern Health’s address redacted for brevity]

Dear Mr Petter

Crisis Management & The Mazars Review

It is clear that the serious delays in publication of the Mazars Review; the Trust’s alleged challenges to the Review; obfuscation over publication date; and its responses to leaked extracts and the final report are achieving the opposite of what they purport to achieve.

I refer for example to the ‘Briefing note’ prepared by Dr Gordon dated 16th November 2015:

“Our primary concern is for the wellbeing of the patient groups that the Trust serves.”

“Well-being, motivation and morale of the Trust’s workforce is [sic] also at the forefront of our consideration….”

It is evident from TV interviews with families and the leak of staff circulars that the Trust’s actions are having exactly the opposite effect. Lack of decisive action is: seriously harming the wellbeing of patient groups and staff morale, whilst Katrina Percy’s mulish refusal to resign; the Board’s failure to suspend her; and allegations of surveillance are equally counter-productive.

There are 15 members of staff in your Communications and Engagement team, which purportedly is responsible for reputation management, yet the Trust’s actions suggest none of them has expertise in Crisis Management – or the Board is not listening to them.

The first principle of Crisis Management is to bring the crisis to an end as quickly as possible to limit negative publicity and move into recovery. Intended or not, the Trust’s actions have served only to extend the crisis and increase negative publicity. So long as this continues, negative publicity will increase and the Trust’s ability to recover decrease – both logarithmically.

Also it appears there is nobody guiding your executive directors on what they should say and write. For example, it was ill-advised of Dr Gordon to make the above comments, which many interpret as insincere, and, whilst reference to, “Killing” people (implying intent) are inexcusable, it is injudicious to give defamatory comments even more publicity by re-publishing them.

I hope you will reflect on this over the next few days and take affirmative action to end this crisis.

Yours sincerely

[Signed]

See more on Crisis Management at: https://999crash.wordpress.com/2015/12/17/crisis-management/

Opposition Party Councillors Gagged!

Now Southampton City Council is at it!

‘The Daily Echo reports that the Council’s spin doctors – led by the Cllr (‘call me Dave’) Shields (Labour) – have tried to gag opposition party members, including Tory MP, Cllr Royston Smith GM, and Cllr Andrew Pope (Independent), from speaking out about the leaked Mazars Review.

Showing total disregard for Council Tax papers, it is alleged that the senior spin doctor asked councillors to tell any residents who make contact with them to instead call the NHS.

And what are ‘Call me Dave’s’ responsibilities? Why, naturally Cabinet Member for Health and Adult Social Care – so that’s all right then.

That’s your sharing-caring social workers for you – or as this Council prefers to call Social Services, ‘People Directorate.’ Silly me, I thought they were there to serve people, not direct them.

‘Call me Dave’ should pick his battles more carefully.

Royston Smith was one of two men who received the George Medal for bravery from the Queen for wrestling a gunman to the floor on board the Royal Navy’s nuclear submarine ‘HMS Astute’ whilst docked in Southampton in April 2011. Able Seaman Ryan Donovan had just shot dead Lt Cdr Ian Molyneux and had seriously wounded another senior officer.

Andrew Pope left the Labour group and criticised his former leader for lacking “vision and strong leadership” and accused him of, “Putting his own position ahead of the people of Southampton” – clearly ‘Call me Dave’ learned from his former leader in respect of his priorities.

Regardless of party affiliations, these are the sort of strong, principled leaders needed to sort out Southern Health and health and social care services generally in Southampton (a unitary authority) and Hampshire. 

Ask the Directors & Governors

Meeting of the Council of Governors – the venue of the next ‘bored’ and governors’ meetings have been announced:

Lyndhurst Community Centre, Main Car Park, Lyndhurst, SO43 7NY

The Board Meeting starts at 09.00 and is scheduled to end at 11.30 hrs.

The Meeting of the Council of Governors is scheduled to run from 14.00 to 17.oo hrs.

There is normally an opportunity for the public to ask questions at both meetings. In the current circumstances, it is likely they will limit questions to one per person so it would be helpful for several patient representatives to attend.

The entrance to the Community Centre is in a public car park so there are no issues relating to being on private property as occurred at a meeting about Southern Health between Oxfordshire County Council and NHS England, reported in the post headed, ‘Mazars, the pop-up display and lives’ at https://mydaftlife.wordpress.com/.

The last time I attended a ‘bored’ meeting there, the Socialist Workers’ Party was picketing outside the meeting for a decent pay rise for low paid Southern Health workers: not a problem that effects the Board!

“Claims hospital refused to help choking Alfie, 3”

On 17 December 2015, this was the front page headline in the ‘New Forest Post’: report dated 16 December on the web site).

A Southern Health hospital (a general hospital with a minor injury unit) allegedly refused to help 3-year old Alfie, who had a £1 coin lodged in his windpipe and was struggling to breath. Having been directed to the hospital (a 5-minute drive away) by the ambulance service, his mother was allegedly turned away by a receptionist, who directed her to Southampton General Hospital without suggesting an ambulance – normally a 16.6-mile, 40-minute drive¹: with heavy traffic (and of course no sirens) it took 90-minutes.

Southampton General rushed Alfie to X-ray and doctors performed an emergency operation to remove the coin. On this basis, his mother’s claim that Alfie could have died seems plausible.

The only reported comments by Southern Health include the normal platitudes:

“We have already taken action to ensure the safety of our patients, including extra training, and new procedures and processes.”

And of course:

“We are unable to comment further whilst the investigation is still underway.”

Questions for Katrina Percy and Dr Lesley Stevens:

The Mazars Review identified serious failings at your mental health and learning disability units, including failures in leadership and management. Are these failings replicated at your hospitals for the physically unwell, for which you are responsible too?

Why did the receptionist not ask a doctor at least to carry out a risk assessment?

Have you recorded this as a Serious Incident: reporting should include ‘near misses’?

Will there be an independent investigation?

Will the family be fully involved in the investigation?

Finally, I suspect the Southampton General tooth-fairy left the £1 coin for Alfie.

Will the Southern Health tooth-fairy – Katrina Percy – visit Alfie and his Mum with a personal apology and a big fat cheque for anxiety and distress – or will she make an insulting offer via a junior official?

¹AA Route Planner

 

Surveillance

There has been debate about the legality of monitoring specific web sites by Southern Health and others. It is my considered view (as a non-lawyer) having done a little research that ‘monitoring‘ is a misleading term for such conduct.

I believe it is,’Surveillance‘, which is unlawful under The Regulation of Investigatory Powers Act 2000.

S.28(1)(a) of the Act refers specifically to, “Directed surveillance.” Ipso facto, ‘monitoring’ a specific web site is “Directed surveillance” and unlawful without proper authorisation.

Monitoring is distinct from surveillance. For example, in medicine, monitoring:

Involves the intermittent performance and analysis of routine measurements (e.g., rabies virus seroprevalence) and observations to detect changes in the environment or health status of a population but without eliciting a response.”¹

Southern Health (and others) are not,’monitoring’ routine issues intermittently, nor are they detecting national changes. They are engaining in ‘directed surveillance‘ – a practice from which they should desist.

The problem is that anyone is entitled to visit a web site as a normal visitor and leave appropriate comments for moderation. What they are not permitted to do is to carry out regular anonymous surveillance.

The problem is that m’learned friends would relish the fees that would accrue from such a technical argument in Court!

¹ http://rabiessurveillanceblueprint.org/1-3-Who-is-it-for

West Hampshire CCG

Well the Mazars Review is published at last (two hours before Parliament rose) and we all have plenty of reading to do.

I received an announcement from West Hampshire CCG: here are extracts from the accompanying email.

“We would like to offer our sincere condolences to any families that may have lost loved ones and are affected by this issue.”

After providing the link to the Mazars Review https://www.england.nhs.uk/south/our-work/ind-invest-reports/ the email continued:

“[The report] highlights a number of actions for regulators, commissioners and the Trust.  A link to our full response to the recommendations can be found here:

“We accept the recommendations made in today’s … report.” As the lead commissioner for Hampshire for mental health and learning disability services, we will work with Southern Health NHS Foundation Trust … to ensure that the recommendations to improve our processes and reporting are implemented.”

We recognise that services for patients in mental health and learning disability need to continue to improve and we are committed to do so.

Since … 2013, we have committed an additional £6 million to mental health services….”

“We continued to work with Southern Health NHS Foundation Trust to ensure that services are safe for these patients.”

“An NHS helpline has been established for anyone directly affected by the Mazars report: 0300 311 2233.”

Note at least in the email:

  • The usual, “Sincere condolences” but no apologies for the failings of Commissioners.
  • The spin: not we will improve but we will “continue to improve.”

Will complete this posting later but right now I’m feeling ill – having just seen KP interviewed on TV.

Continued 18.12.15

I have now read West Hampshire CCG’s response – again full of assurances about what they will ‘continue to do’; no admission of inadequate oversight in the past; and most notably no apologies. 

Crisis Management

 

44694639_mWhilst awaiting publication of the Mazars Review, I have mused over Southern Health’s Crisis Management Skills: skills that are described at length on Wikipedia. Here are some extracts and comment.

 

In ‘The crisis manager: Facing risk and responsibility’ [1997], Dr Otto Lerbinger of Boston University categorized eight types of crises. Southern Health falls into category 5 – Crisis of organizational misdeeds.

In ‘Ongoing crisis communication: Planning, managing, and responding’ [1999] Professor WT Coombs  of the Nicholson School of Communication at University of Central Florida observed:

“Crises occur when management takes actions it knows will harm or place stakeholders at risk for harm without adequate precautions.”

In ‘The crisis manager: Facing risk and responsibility’ Lerbinger specified three different types of crises of organizational misdeeds:

“Crises of skewed management values

Crises of skewed management values are caused when managers favor short-term economic gain and neglect broader social values and stakeholders other than investors. This state of lopsided values is rooted in the classical business creed that focuses on the interests of stockholders and tends to disregard the interests of its other stakeholders such as customers, employees, and the community.”

“Crisis of deception

Crisis of deception occur when management conceals or misrepresents information about itself and its products in its dealing with consumers and others.”

“Crisis of management misconduct

Some crises are caused not only by skewed values and deception but deliberate amorality and illegality.”

In ‘Leadership as (Un)usual: How to Display Competence In Times of Crisis’ [2007], Erika Hayes James, an organizational psychologist and Dean at Emory’s Goizueta Business School, Atlanta identifies two primary types of organizational crisis, which she defines as:

“Any emotionally charged situation that, once it becomes public, invites negative stakeholder reaction and thereby has the potential to threaten the financial well-being, reputation, or survival of the firm or some portion thereof.”

It is evident that James would categorise Southern Health’s position as a, ‘Smouldering Crisis’:

“They differ from sudden crises in that they begin as minor internal issues that, due to manager’s negligence, develop to crisis status. These are situations when leaders are blamed for the crisis and its subsequent effect on the institution in question.”

James categorises five phases of crisis that require specific crisis leadership competencies.

Each phase contains an obstacle that a leader must overcome to improve the structure and operations of an organization. James’s research demonstrates how leadership competencies of integrity, positive intent, capability, mutual respect, and transparency impact the trust-building process. Questions on each of the 5 stages for Southern Health:

Signal detection: where was Southern Health’s leadership when loud alarm bells were ringing?

Preparation and prevention: it is too late for Southern Health’s leadership to prepare for and prevent the current crisis.

Containment and damage control: reverting to James:

“Usually the most vivid stage, the goal of crisis containment and damage control is to limit the reputational, financial, safety, and other threats to firm survival. Crisis handlers work diligently during this stage to bring the crisis to an end as quickly as possible to limit the negative publicity to the organization, and move into the business recovery phase [my emphasis]

Far from containing and controlling damage, every step NHS England and Southern Health have taken to delay and/or discredit the Mazars Review has resulted in loss of containment (i.e. leaks and extensive adverse publicity) and increased reputational damage, thereby unleashing further opprobrium on the leadership.

Business recovery: Southern Health cannot even to start recovery – until they stop digging themselves even deeper into the existing hole.

Learning: Impossible for Southern Health under the current executive leadership – they’ve had over 4-years of ‘learning opportunities’ already.

Crisis leadership:

James also identifies five leadership competencies which facilitate organizational restructuring during and after a crisis:

  • Building an environment of trust.
  • Reforming the organization’s mindset.
  • Identifying obvious and obscure vulnerabilities of the organization.
  • Making wise and rapid decisions as well as taking courageous action.
  • Learning from crisis to effect change.

Crisis leadership research concludes that leadership action in crisis reflects the competency of an organization, because the test of crisis demonstrates how well the institution’s leadership structure serves the organization’s goals and withstands crisis.

On ‘Linking Crisis Management and Leadership Competencies: The Role of Human Resource Development’ (Advances in Developing Human Resources)] [2008], James notes:

Developing effective human resources is vital when building organizational capabilities through crisis management executive leadership.

Readers can make their own judgement on Southern Health’s crisis management ability and award their own star rating to Katrina Percy and others amongst the leadership in respect of the five leadership competencies – after 4-years of ‘learning opportunities’.

Once more I must credit Wikipedia.

Note for Katrina Percy: during your extensive training, did  you go to sleep  during lectures on Crisis Management? I suggest reading the full text at: https://en.wikipedia.org/wiki/Crisis_management#cite_ref-15  where you will find source references too for further ‘learning opportunities’.

Duty of Candour

Musing overnight about the Duty of Candour one wonders how many Southern Health executives and staff have breached the Duty of Candour as registered medical professionals: even those in management roles remain bound by their professional obligations, if they have maintained their professional registration.

The GMC advise they are paying greater attention to management and leadership failings by members in executive positions: I suspect the same will apply to the Nursing & Midwifery Council.

However, although medical professionals’ regulators of will each have their own guidance, all NHS organisations, executives and staff (whether registered professionals or not) should refer to the NHS Litigation Authority’s publication, ‘Duty of Candour – introduction’. Key points are:

“The Duty of Candour is a legal duty on hospital, community and mental health trusts to inform and apologise to patients if there have been mistakes in their care that have led to significant harm.”

“Duty of Candour aims to help patients receive accurate, truthful information from health providers.”

“The NHS LA’s duty of candour guidance seeks to demystify how health providers can deliver on candour, achieving a wholly transparent culture in health provision – being open when errors are made and harm caused.”

Southern Health’s executives and staff ,who spent time in the military, should also take note of The Military Code of Honour, although even those who have not served might reflect on it too.

cropped‎Military Code

Developed by Paul R. Allen, Former Combat Infantryman, U.S. Army 7th Infantry Division, Korea – Purple Heart Medal recipient, Life Member of the Military Order of the Purple Heart, Life Member of the Disabled American Veterans, the Military Code of Honour includes references to how those who have served should act in the civilian world. For example [emphasis added]:

“Back in the civilian world, people have no idea that life is about keeping your word of honor. They think life is about ballgames, backyards, barbecues, babies and business.”

“It is an iron law of nature that such serenity lengthens life span to the max.”

“It is also an iron law of nature that to keep your serenity you must continue to keep your word of honor in civilian life else bad things may happen.”

“It works like this. Unlike civilians who are not trained to keep their word, their honor — the importance of doing your duty and keeping your word of honor was drilled so deep into you by the Military that it became more important than life itself as proven by the fact that you were willing to die to keep it.”

“Consequently if you throw away in civilian life something that important it is only natural to feel a sense of self-betrayal, loss of honor, un-worthiness, etc. These poisonous feelings from trashing your training may grow so powerful they destroy your self-esteem….”

“The lesson: unlike un-trained civilians, veterans must keep their word, their honor/self-esteem in the civilian world like they did in the Warriors World lest their tough training triggers tragic times.”

Full text available at: http://www.militarycodeofhonor.com/WarriorsCodeofHonor

Are there any lessons here for Southern Health’s executives and staff?

Do Southern Health’s staff feel a sense of self-betrayal, loss of honour, un-worthiness as a result of their management’s failings exposed in the Mazars Review?

MIND

Very supportive email from Paul Farmer, Chief Executive of MIND and Chair of the NHS England Mental Health Taskforce. These are extracts:

“The BBC’s report on the Mazars review of Southern Health NHS Trust shows it to be very damning and we agree that the report should be published as soon as possible – please see our comment here. I will be following this up with my contacts at NHS England, in particular through the mental health patient safety group.

On the PHSO [Parliamentary & Health Service Ombudsman] …, the points you raise chime with our evidence to the NHS hospitals complaints system review, though of course the problems are not limited to hospitals. We were critical of the PHSO’s narrow remit and the fact that there is such a big step up between local resolution … and taking it to the PHSO. As the review report said, the PHSO ”is too far removed from where the actions complained of took place and lacks accountability to local people”. Linking PHSO findings to CQC enforcement is essential. We also called for restoration and protection of legal routes of redress – to reinstate legal aid for clinical negligence cases and protect funding for judicial review – but clearly this is not where Government policy is. We will also want to see the new Independent Patient Safety Investigation Service, which starts work in April next year, substantially improving the standards of investigations.

Clinical negligence is a particularly difficult area, though I appreciate you are talking about regulatory and organisational investigations as much as individual legal action. I can see that misdiagnosis or poor clinical judgement may sometimes be difficult issues to assess, but the CQC should have an interest where NHS and other health care providers’ employees’ actions compromise patient safety, and we’ll seek clarification from them about the limits to their role and powers. Complaining to the GMC is another route, if that is relevant to your own case.

Our next major activity on access to justice will be on the Human Right Act when the Government consults on this next year, and we’ll be playing a very active part in this.

You may also like to know that following our campaigning on restraint, there is (among other things) work going on in the Department of Health and NHS England to improve the collection of meaningful data on the use of restraint.”

Unfortunately, the GMC cannot do much when Southern Health ‘loses’ patient data containing evidence of misconduct.

[Other Links to be added].