Disappearing Act 3

I am at a loss to understand why Regulators and Commissioners do not send observers to Southern Health’s Board & Governors’ Meetings.

One told me it was not appropriate to attend because the meetings were an opportunity for the public to ask questions and receive answers. Am I naïve – isn’t this exactly why they should attend?

So, I have sent another Open Email.

“Sent: 24 January 2016 16:37

To: heather.hauschild@westhampshireccg.nhs.uk; Diane Law(whccg.yourfeedback@nhs.net); Meeta Patel (complaints@cqc.org.uk); Tracey.Forester@cqc.org.uk; National Complaints & Enquiries  (feedback@england.nhs.uk); Tom.Grimes@Monitor.gov.uk; Helen.Buckingham@Monitor.gov.uk; Jim.Mackey@Monitor.gov.uk; england.contactus@nhs.net; karen.bennett-wilson@cqc.org.uk; Kirsten.Watson@cqc.org.uk

Cc: sara.ryan@phc.ox.ac.uk; sticeforlb@gmail.com; richardjwest@btinternet.com; andrew.joy@hants.gov.uk; michael.buchanan@bbc.co.uk; maxwell.kusi-obodum@dailyecho.co.uk; councillor.p.lewzey@southampton.gov.uk; dharrison100@aol.com


NHS England: please forward this email to Simon Stevens, Professor Sir Malcolm Grant CBE and Professor Sir Bruce Keogh

CQC: please forward this email to David Behan CBE, Sir Richard Francis QC and David Roberts.


I refer to the email below and am disappointed that not one representative of a Commissioner or Regulator attended the Board Meeting on 11 January as an observer. I note also that nobody had the courtesy to reply.

Without naming names, I understand that one of the organisations feels it inappropriate to send an observer for the perverse reason that the meetings are an opportunity for the public to ask questions!!

That’s exactly why commissioners and regulators should attend – to hear questions, hear (usually evasive) answers, assess the effectiveness (or lack if it) of SHNFT’s directors and governors, and learn what is going on, i.e. nothing to instil confidence.

Moreover, at the Board Meeting, more than one non-executive director of SHNFT agreed that representatives of commissioners and regulators governors should attend to observe. They confirmed also that commissioners and regulators always receive advanced notice of these meetings so my emails should be unnecessary.

Perhaps if I use the hackneyed NHS euphamism, “A learning opportunity” it might persuade you to instruct a colleague to attend.

Compare this with MENCAP – a charity: I spoke to an official at its London HQ on the afternoon of Friday 8th January but she still found it sufficiently important to arrive at the venue for the Board Meeting on Monday 11th January before 08.00hrs. It would be encouraging to see commissioners and regulators taking such a keen interest.

As before, I will copy this separately to other organisations in due course.

It will be interesting to see if a regulator or commissioner attends the next Board and Governors’ meetings – both on the same day, 26th January 2016, at the same venue. 

With kind regards.

Yours sincerely

Contact author of email at crash@marchwood.free-online.co.uk.

Hurricane Katrina

It’s good to post a light-hearted comment.

BBC’s intrepid reporter Michael Buchanan is known to some of us already as the one who door-stepped Katrina Percy and attended the recent meeting of the Council of Governors. His BBC profile includes:

I’ve been fortunate to cover some the biggest stories of the past 2 years including Hurricane Katrina, the conflict in Lebanon and the Ipswich killings.”

Hurricane Katrina Percy – sounds good to me, leaving a trail of spoiled lives in her wake.

That’s two Hurricane Katrinas for you Michael. Spot the difference:



©Full video at http://www.bbc.co.uk/news/health-35074215


cropped Katrina from space©²

Someone on Monday spotted the difference: Hurricane Katrina [Percy] won’t go away! Very droll.

Footnote: Michael’s profile must have been written up several years ago by the BBC – the past two years is a little misleading now in respect of Hurricane Katrina 1.
©² Department of Earth, Atmospheric and Planetary Sciences. Massachusetts Institute of Technology

Disappearance Act 2


“Sent: 10 January 2016 16:30

To: Heather Hauschild (heather.hauschild@westhampshireccg.nhs.uk); Diane Law (whccg.yourfeedback@nhs.net); Meeta Patel (complaints@cqc.org.uk)>; ‘Forester, Tracey’ <Tracey.Forester@cqc.org.uk>; ‘National Complaints & Enquiries’ <feedback@england.nhs.uk>; ‘Tom.Grimes@Monitor.gov.ukHelen.Buckingham@Monitor.gov.uk; Jim.Mackey@Monitor.gov.uk

Cc: Sara Ryan (sara.ryan@phc.ox.ac.uk); ‘Justice for LB’ <justiceforlb@gmail.com>; ‘Richard West’ <richardjwest@btinternet.com>; andrew.joy@hants.gov.uk; michael.buchanan@bbc.co.uk; maxwell.kusi-obodum@dailyecho.co.uk; councillor.p.lewzey@southampton.gov.uk; dharrison100@aol.com

Subject: [OPEN EMAIL] – Why do Regulators and Commissioners appear to be ‘hiding’ from Southern Health’s ‘survivors’ of near-misses and families of the deceased? Importance: High


Complaints Staff – where relevant, please forward this open email immediately as detailed in the pre-amble. It will be published today so it will be extremely embarrassing if anyone approaches your directors and they haven’t seen it.


Where I do not have direct email addresses (or may have ‘guessed’ them incorrectly), this open email is sent via Complaints Managers (and similar) for forwarding. This includes (but is not necessarily limited too) the following addressees:

  1. NHS England – Simon Stevens and Professor Sir Malcolm Grant CBE (who do not reply to my letters anyway) and also Professor Sir Bruce Keogh (who I have not approached before).
  2. Monitor – Jim Mackey, who is (relatively) new.
  3. CQC – David Behan CBE, Sir Richard Francis QC and David Roberts.

I will also be copying it separately to The Secretary of State for Health (via his officials), The National Audit Office and other organisations, whose officials may not wish to be identified specifically.


Why are Regulators and Commissioners apparently ‘hiding’ from Southern Health NHS Foundation Trust’s ‘survivors’ of near-misses and families of the deceased?

At a meeting of the Council of Governors on 8 January 2016, I did not identify a single observer in the public seats representing Monitor, the CQC, NHS England or West Hampshire CCG. (If anyone was present, they did not identify themselves to me.)

When all four organisations are claiming to be acting robustly following the Mazars Review, why did you not take the ‘common sense’ opportunity of meeting unhappy ex-patients and family groups face-to face all at the same time and to hear what the Governors are (or are not) doing? It is self-evident that you should have done so.

I have already challenged Monitor and West Hampshire CCG (via respective Complaints Managers) to send an observer to the upcoming Board Meeting on 11 January 2016 – so this time you two cannot claim ignorance of a meeting. However, if you are all genuinely intent on monitoring Southern Health’s post-Mazars conduct, clearly you should have known about the meetings anyway – by definition, they are part of SHNFT’s alleged post-Mazars improvement plans.

I had planned to write a full Open Letter to you suggesting you send observers to the Board Meeting and noting their absence from the Governors’ Meeting but I ran out of time.

I will send you and publish the full Open Letter in due course, updated once I know which of you send observers on Monday. It is a great disappointment (but unsurprising to many of us) that we have to attempt to shame you by this means into sending observers.

Perhaps in response, you could explain why you are so reluctant (or even refuse) to engage with ex-patients and family groups. Most in-patients, families or even out-patients at the time of inspections (like the Trust’s own staff) will feel very nervous about complaining for fear of reprisals.

There are certain people at CQC who should already [be]having very sleepless nights following the Mazars Review and, in particular, about the death of Connor Sparrowhawk. On or very shortly after 27 January 2012, they knew of a ‘near-miss’ resulting from failure to risk assess a seizure and suspected stroke patient: if the CQC had taken it seriously and acted then, Connor might still be alive.

Connor passed away on 4 July 2013: the CQC had 1½ years to act before his “preventable” death

Monitor – only ‘got away with it’ by ‘the skin of their teeth’: they knew of the near-miss incident on 3 July 2013 so could not intervene within 24-hrs. However, they continue to refuse mulishly to engage fully with the surviving patient and take action – even post-publication of the Mazars Review.

To avoid doubt, I absolve Diane Law (West Hampshire CCG Complaints Manager) of implied criticism in this email. Indeed you could all learn from her diligence, empathy and understanding: it is a pity that (in my opinion) she does not receive the support she deserves from her director

I hope that, for the first time in (up to) 4 years, some of you will start taking me seriously: again Diane Law is excluded.

With kind regards.

Yours sincerely”

Contact author of email at crash@marchwood.free-online.co.uk

Disappearing Act 1

Why are the Regulators and Commissioners ‘hiding’ from Southern Health’s victims and their families?

At the meeting of the Council of Governors, did anyone find an observer in the public seats representing Monitor, the CQC, NHS England or West Hampshire Clinical Commissioning Group? I didn’t.

When all four are claiming to be acting robustly following the Mazars Review, should they not have taken the ‘common sense’ opportunity of meeting unhappy ex-patients and family groups face-to face all at the same time? In case anyone is tempted to reply to this question, it is rhetorical – of course they should have had an observer present.

I have already challenged Monitor and West Hampshire CCG to send an observer to the upcoming Board Meeting – so this time those two cannot claim ignorance of the meeting. However, if they really are genuinely intent on monitoring Southern Health’s post-Mazars conduct, they clearly should have known about the meetings anyway – the meetings are, by definition, part of SHNFT’s post-Mazars alleged improvement plans.

I planned to write an Open Letter to them suggesting they attend the upcoming Board Meeting and noting their absence from the Governors’ Meeting but ran out of time. However, by phone, I have informed Monitor and the CCG of my intent (I have direct line numbers for senior officials there) and that I will confirm it over the weekend in a brief Open Email. If they are not present on Monday, I will just make the full Open Letter one that questions their absence from both meetings!

I will publish the open email here once written and … in due course the full Open Letter. The outcome will be interesting – if predictable! If we cannot shame them into attending, there is no hope – unless the police become involved.

Police – ‘stop press’

The BBC reports that Hampshire Constabulary is considering investigating a complaint against Southern Health made by Richard West.

As a result, they have agreed to reopen a complaint made by a Southern Health ‘survivor’ in 2012: at the time, the Force Solicitor considered it a civil not a criminal matter. In the last three years that ‘victim’ has amassed a large bundle of additional evidence that, taken as a whole and combined with other complainants, might now support the prosecution of a different offence.

Of course, this limits what I can write but many readers will know the story and the name. As a result of the recent meeting of the Council of Governors, the identity of the 2012 complainant potentially is in the public domain already – and certainly is known to the BBC, who recorded the meeting.

If the police do become fully proactive (i.e. by issuing a Crime Number), will this finally shame the Board sufficiently to suspend Katrina Percy and Lesley Stevens … or will they simply use a police investigation as another excuse to delay taking any action at all? I suspect we all know the answer.

Governors Meeting

If today’s meeting achieved anything, the Governors went away shocked at the extent to which they have been kept in the dark by the Board. The Governors agreed to the whole meeting being recorded in sound and in vision. Two television crews recorded the meeting and Michael Buchanan of the BBC was present throughout.

The press and public were allowed to ask questions without limits being imposed:  their questions were robust and to the point -significantly more so (with notable exceptions) than questions, which the Governors posed to the Directors.

There were three disappointments:

  • Two governors chickened out and left when the others voted to allow media to record the meeting. Surprisingly this included Helen Keats, even though she was present only by telephone link.
  • There appears to be no inclination to hold to account those  responsible for the 4-year failure of leadership, identified unequivocally by Mazars, or even to carry out disciplinary inquiries into their conduct.
  • It was evident that the non-executive directors had been asleep on the job – or (in fairness) kept in the dark too.

As the meeting was recorded in full, one hopes that a full transcript will be published in fairly short order.

Roll on the Extraordinary Board Meeting on 11 January 2016 but be alert to last minute changes.

Welcome to 2016

We start the year with a letter to the Council of Governors in advance of their Extraordinary Meeting on 5 January 2016.

4 January 2016

By email only: governors@southernhealth.nhs.uk

Cherry Barney; Andrew Jackman; Arthur Monks; John Green; Sue Smith Susie Scorer; Claire Hughes; Josie Metcher; Tom Whicher; Bill Webber; Helen Keats MBE; Mark Aspinall; Maureen Norton; Vicky Melville; Nick Sergeant; Paul Valentine; Liz Hall MBE; Cllr Andrew Joy; Cllr Paul Lewsey Janet Chiera MBE; Rick Smith; Professor Clive Holmes

Dear Governors

I refer to the letter from Sara Ryan and Richard Huggins to you dated 2 January 2016, sent by email. I fully concur with the comments therein and can back up most of them from personal experience as a ‘victim’ of the Trust, who survived.

Notwithstanding the conclusions reached by Mazars, I suggest respectfully that the Governors pay due regard to the lack of crisis management expertise amongst the Trust’s Directors and executives. Please see my open letter to Mike Petter of 22 December 2015 (attached).

The Trust’s conduct from the time it became aware of the likely content of the Mazars Review has been shambolic and counterproductive. There is no excuse: it had been evident for many months that the Mazars Review would be highly critical of the Trust so its Executive Directors had ample time to prepare a crisis management plan before publication.

In any organisation, the key to successful crisis management is immediate, decisive action to minimise reputational damage; safeguard the well-being of customers; and preserve staff morale. Clearly, no such plan was in place. As a result, the Trust’s actions had exactly the opposite effect: patient groups and staff perceived that Executive Directors simply were protecting their own interests.

One only has to read the Executive Summary of the Mazars Review ‘Leadership and board oversight of deaths‘ (pages 17 to 19) to know where the buck stops. There alone, words such as ‘poor leadership’; ‘Failure of leadership and governance‘; ‘lack of focus’; and ‘no effective action’ speak for themselves.

I respectfully suggest that the Council of Governors exercise its influence over the Board by counselling hem to take decisive action including immediate suspension of Katrina Percy and Dr Lesley Stevens ending a full disciplinary inquiry.

Only then do I believe that the Trust can move into the ‘recovery’ phase. If time allows, I will send you very brief summary of my personal experience later.

Yours faithfully