It’s over…

19839392 - breaking up in a ugly messy relationship





Dr Paul Lelliott, Deputy Chief Inspector of Hospitals and Mental Health Lead at the Care Quality Commission and two regional CQC officials met Healthwatch Hampshire and members of ‘The Forum for Justice Accountability & Equality at Southern Health’¹,² on Friday in Winchester.

In a press release on 22 November 2016, the CQC implied that significant improvements had been found at an inspection of the Trust on 13 – 15 September 2016. Yet the report itself referred to on-going environmental issues relating to ligature risks, the layout of some wards and insufficient staff which did not may it easy to observe patients – including those who might be at risk of self-harm. In addition, local management teams had not consistently reviewed and learnt from incidents well.

Southern Health even told the CQC that every patient had in place an individual safety and risk management plan, relating to the ward environment but they found no such plan existed for a quarter of the records reviewed. The CQC raised these concerns with Southern Health at the time of the inspection in September not when the report was finally published. Read the full report here→

Commenting on the latest unexpected death by ligature of a Southern Health patient last week and developments over the last 12 months, a spokesman for the Forum said:

“We were deeply saddened by the news of another unexpected death of a Southern Health patient. Our hearts go out to the family: we share their grief. We cannot speculate without further information but, in the context of the CQC report, the obvious question is how can a patient, on 15 minute observations, use a bed-sheet as a ligature without it being attached to a fixed point? We are shocked by the tone of Southern Health’s announcement too. They might as well be reporting that the coffee machine had broken. It appears to be all about managing reputational risk again.

“In our view, the twelve months since publication of the Mazars Review and our meetings have demonstrated not only the continuing failure of leadership and governance at Southern Health but also that neither the CQC nor NHS Improvement are effective regulators. During this time, there have been more Inquests, more Coroner’s verdicts, more CQC Reports, more NHS Improvement Enforcement Notices and more sadness and reports from bereaved families and others. There has been plenty of tea and sympathy, but no discernible action.

“Critically, it appears the CQC does not monitor the Trust Medical Director’s implementation of Action Plans arising from Coroners’ Courts or from the Parliamentary and Health Service Ombudsman and, in practice, does not monitor the long-term execution of any action plans. “These are vital because the Plans are requested to address failings in patient care. It demonstrates that the Trust continues to jeopardise the safety and lives of patients.

“Conversely, the Forum is encouraged by the actions of the new Interim Chairman, Alan Yates, who appears keen to engage with patients, bereaved families, ex-governors and others, and with the few existing governors, who truly wish to improve things. To this end, the Forum has asked NHS Improvement and the CQC to give Alan every support in implementing his plans. Also, members of the Forum were delighted when Dr Lelliott and his colleagues agreed to consult them before, or at the start of, future inspections of Southern Health.”

The Forum concluded:

break-up-3Sadly, we have reached the conclusion that, unless positive steps are ‘seen to be’ taken in short order to improve governance, patient safety and leadership at the Trust (especially medical leadership) the only option is for the Trust to be broken up completely. Meanwhile, Alan Yates and the Regulators can be assured of our support.”


¹ The Forum is an influential group of bereaved families, carers, ‘rebel’ governors and others, who came together last May at ‘The Shambles‘ to exchange views and who are determined to see real improvements at Southern Health.² Members have held meetings with a Minister of State, Directors of the CQC, NHS Improvement and Southern Health, The National Audit Office, Healthwatch Hampshire and others. Further such meetings are planned. Members act individually on their own cases too.  


Members of The Forum, who attended the meeting with Dr Lelliott, photographed at the venue – The Lakeside Room at South Winchester Golf Club.  ©John Green.

Anyone with an interest in joining ‘The Forum for Justice Accountability & Equality at Southern Health’ should email brief details by clicking here:


This blog (CRASH) is authored by a member of ‘The Forum for Justice Accountability & Equality at Southern Health’ but does not speak for or represent the views of the Forum, unless specifically stated as comments by a ‘spokesman’ for the Forum. In the latter case, statements are based on the majority view and are vetted by at least three members of the Forum before publication.


6 thoughts on “It’s over…

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