How many alarms does it take to wake up Southern Health!

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A, “Wake-up call” for Southern Health, Coroner Grahame Short told an inquest in Winchester on 27 September 2016.

 

Full marks to our friends at the BBC for their coverage of events relating to Southern Health – three reporters and three cameramen all ‘on their case’ in one day!

Michael Buchanan reported on the Inquest into the sad death of Marion Munns for the national news, whilst David Fenton did so for regional news. BBC South news linked David’s report cleverly to Steve Humphrey who interviewed bereaved families and other campaigners after their second meeting with Southern Health’s Interim Chief Executive and Nursing Director, facilitated by Healthwatch Hampshire.

Inquest Marion Munns

Followers of Southern Health’s tragic history were unsurprised by the verdict – another preventable death. In addition to, “A wake up call” the Coroner said Southern Health had failed to put in place care plans or a risk assessment.

Even more concerning, coroner Grahame Short, whilst acknowledging there had been failings within the Trust regarding Marion’s care,  allegedly agreed also there had been significant policy changes since the tragedy. Read more→ .  One would like to ask Mr Short why, in the light of previous Inquests, he has such confidence that the Trust has learned from this latest event and how many of his previous findings of fault were remedied.

In a statement, Southern Health said it had made, “Comprehensive changes” to its Older Persons Mental Health Service. Of course it did – we shall see.

Meeting

Facilitated by Healthwatch Hampshire, a group of campaigners for reform at Southern Health (“the Group”) met Interim Chief Executive, Julie Dawes, Interim Director of Nursing, Sara Courtney and Head of External Communications, Liz Pusey at South Winchester Golf Club.

This statement was issued to the media after the meeting. “We” is the group.

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Contrast this with the views of governors, who claimed only two days earlier to have, “Heard and understood” the views of patients, families and the community: read more→.

The governors are living in ‘La-La Land.’ 

On learning the Coroner’s comment about, ‘A Wake-up Call’, one of the Group quipped:

“They must have a load of alarm clocks going off at Tatchbury Mount.”

Which begs the question:

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The slippery slope

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We have said before that Southern Health lurches from one crisis to the next. 

Only they could manage three public relations disasters in one day – 25 October 2016.

 

 

Board Meeting

In the morning, the Trust published the Carolan Report. Stephanie Carolan made a thorough , hard-hitting presentation to the Board Meeting (held in public). The full text of her report can be downloaded here→.

The bad news is that Stephany’s report highlighted exactly what families have been telling Southern Health (including Dr Lesley ‘Slippery’ Stevens) for over three years – especially about engaging with families. Stephany even highlighted the importance, not just of engaging with families after death, but also with families as soon as new mental health or learning disability patients are referred to the Trust.

Family engagement appears to be a new concept in adult care for Southern Health. One of its Consultants, the excellent Dr Mayura Deshpande, who specialises in Adolescent Forensic Psychiatry, gave a presentation on the subject at the AGM, emphasising its  importance. Was it too much for Southern Health to listen to their own Consultants and extend the principle to adults?

In the private sector, one of the first things Consultants wish to do is to speak to the family! It should be standard practice, not ‘news’. 

Unfortunately, we missed public questions – couldn’t resist the temptation to talk to a Deloitte official about the practices at her firm as reported here→ and here→

However, we understand that a bereaved family member ‘took Dr Stevens apart’ with his questions and comments. We look forward to hearing the recording.

Council of Governors (“CoG”) Meeting

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A complete farce – a car crash – frozen in headlights like frightened rabbits.

 

 

Regular readers (with a good memory) might recall that resolutions to remove certain Non-effective Executive Directors were first considered long ago but postponed for consideration. On 17 May 2016, Tim ‘Not-so’ Smart cancelled the Emergency Meeting to enable the CoG to ensure the resolutions were legally valid. He undertook to reconvene it, “Shortly.

Now,  five months later, one would expect the resolutions to be absolutely watertight – that is if it were any other Trust than Southern Health. But no, most of the governors left it until the meeting itself before receiving the legal advice only to be advised that some of the resolutions are still considered unlawful!

So we (taxpayers) were paying two firms of solicitors (Blake Morgan advising the CoG) and Southern Health’s friends solicitors (Capsticks) to run around like headless chickens whilst the public were excluded. (The CoG voted not to waive legal professional privilege so that we – the public, who they purport to represent – did not hear the legal argument.) 

Additionally, it appears that the meeting was not quorate for some resolutions even to be passed – owing largely to the absence of all four staff governors. A fix? Perish the thought!

In short, in our opinion, the governors individually (with notable exceptions) and the CoG(as a group) are demonstrably not fit for purpose and riddled with conflicts of interest. Three of the resolutions that were voted upon illustrate this nicely.

“Resolution 1)  [The Council] has no confidence in the Trust Board.”

The CoG voted against – i.e. they have confidence in the Board.

Resolution 5) The CoG of Southern Health (NHS) Foundation Trust sends a clear message to the patients, their families and the community that this Council, as their representative body, has both heard and understood them.

The CoG voted in favour. ABSURD – if the Council has heard and understood the views of patients, their families and the community, how could they possibly have confidence in the Board (resolution 1)? Moreover, the governors had not received the Carolan Report or the Minutes of a meeting with these parties facilitated by Healthwatch Hampshire on 23 September 2016, so clearly they had not ‘heard’ (much less understood) these views.

And it gets worse:

“Resolution 13) The CoG of Southern Health NHS Foundation Trust hereby resolves to establish a committee of the CoG to be known as the Governors Public Consultation and Communication Strategy committee…. [duties etc.] set out in Appendix 1….”

The purpose in Appendix 1:

“This Committee is responsible for creating, updating and reviewing a strategy for the CoG which promotes and supports the duty of Governors either as a body or individually to consult with the members of the Trust and with the Public and for the CoG either as a body or individually to communicate to the member of the Trust and to the Public such information as properly ought to be communicated to them.”

Yet the CoG voted down this constructive and perfectly logical proposal. From the absurd to the RIDICULOUS. The governors do not want to improve feedback from patients, their families and the community – even though that is their role in life. They don’t really want the work and hassle of being effective governors. The CoG effectively resigned.

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The Three Wise Monkeys would do better.  

 

 

Inquest latest

First reports of the inquest into the sad death of Marion Munns, which started on 24th. September, started to emerge.

It is alleged that a Consultant Psychiatrist, Dr Vicki Osmond-Hicks diagnosed Marion by phone, as not needing to be seen, and did not put Marion on the risk register. Apparently, adult mental health services (even in a crisis) are not available after 17.00 hrs. A care worker told her daughter that they could not respond to a “crisis call” because the office was about to close for the day! Read more→

But then, what does one expect when the Trust’s Medical Director,  Dr Lesley ‘Slippery’ Stevens, known also as ‘Mystic Meg Lesley’ diagnoses a person she has never met or spoken to at all – much less on the telephone.

Footnote: Dr Vicki Osmond Hicks is part of The Undergraduate Medical Education team, which coordinates teaching for Southampton Medical students in Psychiatry.  She is Lead Tutor for the Southampton Hub. Read Victoria’s Story.

And finally:

How much of our money has Southern Health spent this week on lawyers and consultants?

Capsticks, Blake Morgan and Deloitte for the Board and/or Governors’ meeting on 25th September and probably solicitor(s) and barrister(s) for the 4-day Inquest. And that’s excluding preparation time. As Barten Holyday [1593–1661] once said:

A man may as well open an oyster without a knife, as a lawyer’s mouth without a fee!

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And so, Southern Health carries on down the slippery slope.

 

 

Too honest to work in the NHS?

“NHS whistle-blower told she was ‘too honest’ to work for the health service” [Daily Telegraph 3rd April 2016]

Unbelievably, NHS whistle-blower, Maha Yassaie, chief pharmacist at the now defunct Berkshire West Primary Care Trust, who raised concerns about patient safety, was told she was too honest to work for the organisation! According to a transcript of the conversation, the investigator, Kevin Cheatle allegedly told Maha during a meeting:

“If I had your values I  would find it very difficult to work in the NHS.”

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Now another hugely courageous  whistle-blower – Jade Taylor – went on hunger strike outside The Department of Health last week.

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An ardent campaigner for improvement, NHS Manager Jade Taylor attended a meeting with a group of Southern Health’s bereaved families, carers and rebel governors on 17 May 2016 –  a meeting commonly known as ‘The Shambles‘ in Lyndhurst: read more→

Jade is acutely aware of safety issues after both her late mother and late stepfather suffered whilst receiving ‘care’ at the now defunct Mid Staffordshire NHS Foundation Trust. Her stepfather died after contracting an infection following surgery. Then in 2008, her mother, who suffered Alzheimer’s disease was allegedly discharged inappropriately on her own from Stafford Hospital, which caused considerable distress to the family.

Jade left ‘The Shambles’ in tears on realising that nothing had changed  since the tragic events at Mid Staffs, exposed by The Francis Report in 2013. Since then she has given generous moral support and assistance to Southern Health campaigners.

Now, having spoken up on behalf of patients in her role at Berkshire NHS Foundation Trust and having been off sick for about a year due to stress and a mild heart condition, Jade faces the prospect of being dismissed herself.

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Over the last three years, Jade has raised, “A plethora of concerns” about a number of issues, including unsafe staffing levels, bullying from senior managers and an, “Unsafe referral pathway.” She told CRASH:

“Because of these experiences – whistle-blowing was a real issue in Stafford – I’m not going to give up raising concerns. My late Mum and Stepdad were in the Mid Staffs disaster, which has had its own impact. Now I have raised concerns, which haven’t always been handled well, at the process to support me through it has not been helpful at all.”

And despite her ill-health, Jade, who has worked for the Berkshire Trust for five years, says that she had not received an occupational health assessment, despite being off work for more than a year.

When asked why the Trust is dismissing her, Jade said:

“They are saying that I have lost trust and confidence in them. I am not resigning and I want to work at the Trust. I haven’t lost confidence in them: I just want them to deal with investigations properly.”

Jade has previously met The Secretary of State for Health, Jeremy Hunt to discuss the way whistle-blowers are treated in the health services  and gave evidence to Sir Robert Francis’s Freedom to Speak Review. She summarises her case:

“This is another case of reprisals against whistle-blowers really.”

Naturally, Berkshire Healthcare NHS Foundation Trust refused to respond to press enquiries because, “We respect her [Jade’s] right to confidentiality.” What about respecting her honesty and integrity too? 

And reverting to honesty and the investigator, Kevin Cheatle, who told Maha Yassaie that her values made it very difficult to work in the NHS, those familiar with solicitors and consultants used regularly by the NHS will recognise his employers – the NHS’s friends solicitors, Capsticks.

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So Jade has now lost her parents, probably her job and possibly her home thanks to the NHS.

 

© SWNS

 

Come on Mr Hunt, the NHS is short of nurses and recruits overseas – yet you allow it to throw conscientious whistle-blowers like Jade, Maha and others on the scrapheap for the ‘sin’ of reporting safety concerns and trying to make a difference.

Message to Southern Health: if Jade is dismissed from her position at the Berkshire Trust (news expected this week), why not offer her a job. This would be really compelling evidence of your intention to reform.  

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And a special thank you to SWNS for providing the images of Jade on this page to CRASH on a complimentary basis.

 

 

 

SWNS is the biggest independent news wire in the UK – providing news, pictures, PR and features to media organisations around the world. They  specialise in news, real-life human interest features, photography, video, syndication , PR and market research, employing more than 100 editorial staff across offices in London, Plymouth, Cambridge, Birmingham, Glasgow, Aberdeen and Yorkshire.

Troubled Waters

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Having reported positive developments – meeting with the National Audit Office and the glimmer of light shining at the AGM on 6 September – we return to troubled waters.

ANNUAL GENERAL MEETING

Despite the glimmer of light, which shone whilst socialising after the meeting, , the overall feedback was universally negative.

You can now hear the full audio recording of the formal meeting here→ and judge for yourself. To miss routine business, fast forward to circa 56 minutes for question time. It is well worth a listen, especially:

  1. Interim Finance Director, Paula Anderson talks about not being happy with certain aspects of procurement procedures in the contract awarded to Talent Works and that internal audit had identified it some time ago. If “internal audit” identified it, what did Spires (Chair of Audit Subcommittee) do about it? That’s rhetorical – I think we all know the answer.
  2. Shortly after Paula said this, Smart claims that he and his independent consultants had no evidence that Katrina Percy had done anything wrong! Did he not talk or listen to his Interim Finance Director.
  3. Smart dismisses proof of Katrina Percy colluding with Deloitte LLP to mislead the Department of Health and Southampton CCG as evidence that she had done anything wrong.
  4. Southern Health using super-gagging orders to silence whistle-blowers: someone later referred to the questioner “disembowelling” Tim Smart.
  5. Hear Smart muttering “ridiculous” towards two of us – obviously forgot the mike! That’s how much respect he has for those seeking justice from Southern Health.

We started to receive emails at 20.45 hrs on the same evening: the first stated: 

“So appalled at tonight’s meeting that I missed my turn off tonight and drove to Farnham.”

And another, “What a farce!”

In all, we received 56 emails on the subject of the AGM – 5 on the same evening, 28 on Wednesday and 23 on Thursday, along with a significant number of telephone calls. Save for positive comments about selected directors reported previously, none of them were positive about the Trust overall: some were unrepeatable.

NHS IMPROVEMENT

Having found National Audit Office officials welcoming, constructive and keen to listen to evidence relating to value for money and procurement practices at Southern Wealth when we met them on 29 September, some of us went on to NHS Improvement’s Board Meeting – to be joined by two others.

Here we found the attitude towards questions about Southern Health positively hostile – but watch the video and decide for yourselves!

  1. The Chairman offering a private meeting to discuss what happens next at Southern Health, “Provided it remains private.” So what happens next is a private matter and the citizens of Hampshire do not have a right to know. How’s that for being open and transparent in matters of public interest?
  2. The CEO denying his previous Trust used super-gags– despite a Freedom of Information response showing otherwise – the Chairman considers the question inappropriate; refuses to answer; and threatens to close the meeting to the public.
  3. The CEO failing to explain why NHSI claimed on 4 July 2016 to be working closely with the CQC and Healthwatch to improve things at Southern Health when Healthwatch denied it and also denying that he had any knowledge of an invitation from Healthwatch Hampshire to a meeting with bereaved families and others, despite one of his colleagues having acknowledged the invitation.
  4. The Chairman answering a Jim Mackey fan: he emphasises what NHSI is allegedly doing with other regional organisations. No mention of Healthwatch!

It is evident that NHS Improvement was highly embarrassed by the presence of our group and its failed ‘improvement plan’. Simply, they didn’t want a public discussion.As Corporal Jones would have said, “They don’t like it up ‘em.”

NHS ENGLAND

One of us had attended the NHS England Board Meeting that morning too, hoping to get clarification of exactly who is responsible for this mess. NHS England simply referred him to NHS Improvement.

So that just about summarises the events of 29 September and the earlier AGM.

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The only organisation giving us any confidence that they will take issues relating to Southern Health seriously is not part of the NHS at all – it is in the National Audit Office – and ‘normal procedures’ require them to go through NHS Improvement anyway.

Value for money?

 

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By splitting resources, patient representatives and selected governors attended three meetings in London on 29 September 2016 – NHS England and NHS Improvement (“NHSI”) Board Meetings and a private meeting at the National Audit Office (“NAO”).

 

 

NATIONAL AUDIT OFFICE

Four patient representatives and a governor met two senior officials: for legal reasons, we are limited on what we can report.

WORK IN HAND

The NAO described its current position in relation Southern Health.

  • Continuously monitoring the Trust.
  • Talent Works contract and Katrina Percy’s salary are issues of “value for money,” which is one of their remits.
  • Raised the issues with NHSI and await a response.
  • In ‘listening mode’ and would use what we said to aid interpretation of information received from others, including NHSI.
  • The officials responded to concerns about NHSI’s honesty and transparency with confirmation that they have powers to seek information directly.
  • Will use data for other Trusts to benchmark consultancy spend at Southern Health relative to others.
  • They confirmed that all works of above £20k should go through competitive tendering.
  • They cannot commit to what they do next or timescales: very much depends on the information they get back and what they find.

We had the impression it was early days and they were giving people (in the NHS) an opportunity to do the right thing before they took a more heavy-handed approach if it proved warranted.

AREAS OF CONCERN

We addressed five major areas of concern, noting also Trevor “Honest John” Spires and his position at the Rural Payments Agency, which the NAO has seriously criticised already inter alia for, “Poor and dysfunctional leadership and wasting public money“: read more →. Where have we heard that before?

Talent Works Contract:

We posed the following questions about the contract with Talent Works:

  • Were proper procurement process followed for the tendering of this work in 2011 and 2015?  FOI  response to a governor provides heavily redacted tender documentation?
  • Are there any notes on the evaluation of competing tenders that justify the award to Talent Works?
  • Who were the other bidders?
  • What were the decision criteria?
  • Is it usual for “call off” contracts to grow by such a large extent? They are usually used where the scope of work is unclear and develops during the engagement.
  • Why wasn’t a scoping study commissioned and then the next phases bid competitively? This is normal commercial procurement practice.
  • Was the contract properly managed with appropriate governance oversight on payments made for work delivered?
  • What where the roles of the Finance Director, Audit Committee and Internal and External Auditors in this process? It would not appear to be in line with Southern Health Standing Finance Instructions that limit growth of contracts to 10%.

We have since submitted a new FOI request to clarify some of these points.

We noted:

Carolan Consultants Contract:

Carolan Consultants is a trading name of WorkGuru Ltd – read about its services here→

Engaged to carry out an “appreciative inquiry” study into family experiences. The contract was quoted at £22,500 (FOI1284),  but one payment of £22,500  was made in 2015/16 and a second of £22,500 in 2016/17 (FOI1409), making a total of £45,000 (excluding VAT). There was no competitive tendering and there is no evidence of a second contract being agreed.

There are several issues arising from FOI1284, which warrant further study.

Unusually large payments to GPs:

It is evident that Southern Health makes small payments to GP practices and pharmacies in the community to support specific initiatives. Smoking Cessation and Service Integration and Joint Working are two such initiatives. 28 surgeries received payments for  “Service Integration and Joint Working” in the first half of 2016/17 (FOI1409).

However, an abnormally large payment of £29,950 was made during 2015/16 to Dr J A Barton and Partners in Gosport for “Service Integration and Joint Working” (FOI1409). This practice now operates as Forton Medical Centre  following the retirement of Dr Barton. Both practice names share the same telephone number. In addition, the Forton Medical Centre practice received £4,372 in the first half of 2016/17 for the same purpose: this is more consistent with other surgeries (FOI1409).

Dr Barton was the subject of a very high profile case in 2010: she was found guilty of overprescribing medication to elderly patients at Gosport War Memorial Hospital, which accelerated their deaths. Although spared by the GMC, she voluntarily removed herself from the medical register in 2011.

  • Why was the former name of the surgery used for the large payment (when the new name is used elsewhere), particularly given the bad history?
  • Why is there a need for such a large payment to be made?

We noted that Dr Lesley Stevens, Medical Director at Southern Health is a partner at the Forton Road practice. (Southern Health Annual Report and Accounts 2015/16).

In addition North Baddesley Surgery received £15,800 in the first half of 2016/17 for “Service Integration and Joint Working.”Sarah Schofield, Chair of West Hampshire Clinical Commissioning Group was a partner at North Baddesley Health Practice until early 2015. Again, what was the need for such a large payment.?

Payments to legal and consultancy firms (including for Inquests and to Deloitte): 

The Trust spent £550,000 in 2015/16 and £214,000 in the first half of 2016/17 on external legal support. Why is this necessary?

This would include support for their attendance at Inquests, and in preparing letters to members of the public, patients and governors threatening legal action. Mitigation of reputational risk is their key consideration – not patients.

In comparison, the Trust withdraw legal support from members of staff prepared to give evidence against the Trust, for example at Connor Sparrowhawk’s inquest. The Trust left his family to pick up a bill of £78,982 (excluding VAT) for legal support for Trust staff on top of the families own bill. Read more→

At a Family Listening Day in London on the 22 September 2016 hosted by the CQC and facilitated by the charity Inquest, a family member produced a letter from the Department of Justice. It was a response to the concern that financial support for legal costs is not offered to families despite the Trusts funding highly aggressive lawyers and barristers to represent the Trust. The DoJ response was that an Inquest should be an informal legal process not normally requiring legal representation of the parties. Why therefore are Trusts permitted to spend so greatly on lawyers for the purpose it seems of protecting their reputation?

Katrina Percy’s salary in her ‘new’ role:  

What is the justification for KP’s salary in her new role? Professor Chris Hatton has suggested that the maximum salary of a top job grade is £99,000. Why does she get double that? Why also is she apparently maintaining executive director-level pension benefits?

Board Capability Review:

Upon his appointment Mr Smart commissioned two reviews of board capability by external consultants. Through FOI responses one of these firms, YSC Ltd, has received £116,000 to date. This level of commitment is in excess of his approval level.  

Was due process followed in getting this level of expenditure approved and in appointing the successful bidder? Their brief and report are not in the public domain. To the best of our knowledge and belief, the Consultants did not approach any bereaved families, other patient representatives or governors to obtain evidence.

The Chairman of YSC Ltd,  Gurnek Bains lists his outside interests as, “In spread betting (on anything) and in creative photography.” “Anything?” – effectively, Gurnek your Board Capability Review has bet on patients’ lives. 

Jeremy Kyle and his lie-detector expert would have been cheaper – and more effective!

And the result – another three months angst for bereaved families and other campaigners before the inevitable happened and Percy had to go anyway. So that was money well spent!

VALUE FOR MONEY

We pointed out that all this money is being spent items of questionable value when, for example there is an inability to provide effective training to front line staff in Basic Life Support and Epilepsy Awareness and a serious shortage of beds. 

Also, the Trust closed Woodhaven Hospital (a ‘state of the art’ purpose designed and built hospital for adult mental health patients) on the basis of unrepresentative occupancy data to support the business case for conversion to a forensic unit at a cost of £3 million. The Trust expected to earn money by taking in forensic patients from other areas. Read more in ‘Hansard’ here→

The demand turned out to be over-estimated, so that (apart from housing patients from other units at threat of closure by the CQC while building alterations went on) it has remained largely empty. Far from raising income, huge overspends (believed to be in the order of £6 million) are now being incurred by Southern Health due to a woeful shortage of beds for adult mental health patients and out of area placements (including in the private sector).

GOVERNORS’ ROLE 

[Redacted] acknowledged the large number of FOI requests he has lodged and stated this was the only way he could get information. There was no communication from the Lead Governor, who should supply this information. He stated he only learns of key events by watching the BBC News and believes the Trust has spent £20,000 blocking Governors from taking action. 

WHAT HAPPENS NEXT?

The NAO will continue to monitor developments and confirmed that the information received was useful. They took copious notes but could not say how it might develop or when. They noted also: 

  • The NAO has an ongoing programme of work on mental health, which is still in the scoping phase.
  • Both officials have very close connections with South Hampshire so there was a sense of personal engagement with issues relating to Southern Health.
  • We will continue to supply any evidence arising to the NAO.

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And so on to NHS Improvement – a meeting to be reported separately – along with NHS England.

 

Minutes or Seconds?

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Another of Southern Health’s cunning stunts was uncovered last week – censoring abridging Meeting Minutes to deflect the truth. It is more accurate to refer to the Minutes as Seconds!

As examples, we refer to questions/statements from the public at July’s Board Meeting and the answers provided … or not as the case may be! 

 

Read one of the statements and questions here: it filled three A4 pages.

By the time it appeared in the draft Minutes, Southern Health had reduced it (and the non-answer) to just six lines of A4:

“[Redacted] presented the Interim Chair with a number of questions, highlighting in particular the cancellation of the extraordinary Council of Governors meeting scheduled for 17.072016, the Interim Chair’s findings report published on 30.06.2016 and a letter he had received from the Interim Chair on 23.06.16. The Interim Chair advised that he would consider how best to respond to the questions put forward….”

The allegations of bullying against the Interim Chair; his failure to meet bereaved families and others as part of the Board Capability Review; and the evidence of Katrina Percy colluding with Deloitte to mislead the Department of Health and Southampton CCG etc.?

Consigned to the bin! And to complete the story, the Interim Chair decided the best response was no response at all!

Another question was:

“What, specifically, is the Trust going to do to address the thousands of unexpected deaths that occurred between 2011 and 2015 that were not investigated, and those unexpected deaths that were inadequately investigated – such as the death of [redacted]?

“The Trust, have a duty to ensure that the deaths of individuals like [redacted] are investigated properly- that has not happened. Those unexpected deaths haven’t gone away either – and they won’t go away. What is the Trust actually doing to address the fact that these unexpected deaths still remain un-investigated? “

The public gasped in disbelief when Dr Gordon stated that there were only nine unexpected deaths in that category. But the draft minutes record:

“[Redacted] member of the public, presented a question on behalf of [redacted] concerning what the Trust was doing to investigate the unexpected deaths between 2012 and 2015, and deaths that were not investigated. Chris Gordon advised in response that the Trust had taken all the necessary action required of it in this category.”

No mention of, “Nine” – how very convenient!

It transpired that such reduction of Seconds Minutes is not knew. Not only is it misleading but also it conceals hides vital records, which in the future could be invaluable in holding Directors to account in the future.

There’s no better example than the Minutes of a meeting, at which governors gave serious risk warnings before the takeover of Ridgeway. From 2011, a governor describes issues being raised as:

“Routinely watered down or eliminated from the minutes.”

At a 2012 meeting, two governors took Katrina Percy to task over the proposed acquisition of Ridgeway. One has commented:

“I spent a few minutes probing the risks and enquiring about due diligence in some detail. I also pointed out that acquisitions very often fail because of IT or cultural differences, or simply because they are too big and too difficult to integrate. I had the usual KP gloss and fluff reassurance that they had a great team doing the integration and a detailed plan. What was amusing is she came over to me when the meeting had finished and said how much she enjoyed my robust questioning, of course she did.

So they have been slippery for years.

They missed everything I said about due diligence and acquisition problems from Minutes, [expletive deleted].”

In the Minutes, Southern Health reduced all the comments about risk, due diligence, integration and acquisition to:

2016-10-03-2016-10-03-001-001

We wonder: which directors/managers made up, “The dedicated leadership team”; and which members of the Board scrutinised the plans. Freedom of Information Request anyone?

The Minutes record the other question and answer thus:

2016-10-03-2016-10-03-002-001

Preaching quality leadership … and giving Ridgeway the benefit of Going Viral leadership programme – that worked well then! Just search ‘Ridgeway’ here to see how well the dedicated leadership team and Going Viral leadership programme worked.

So ‘adapting’ Minutes to favour and protect Trust directors has been an ongoing practice throughout Katrina Percy’s reign.

Moral: members of the public and governors, who ask questions or make statements, must check draft Minutes diligently – or email the full text in Word to Anna Williams and insist it is cut and pasted verbatim into the Minutes. Also, use every opportunity to challenge the accuracy of Minutes. 

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Advice to Southern Health – if you want advice on reputation management look here and kick the censor into touch.

Your victims have long memories.