A week in the life of Southern
6 March 2017: the CQC informs Southern Health of its decision to prosecute the Trust for a health and safety incident, which took place in December 2015 at Melbury Lodge.
The incident involved a patient getting on the roof and falling from it, injuring himself. Read more→
We have obtained a copy of an internal email sent to Southern Health staff by the Trust’s Interim CEO. Amongst the platitudes:
“As you know the safety of the people that use our services is central to everything we do…. The work [subsequent improvements at Melbury Lodge] will not only make the ward safer for patients but it will be a much more therapeutic environment.”
So why the ongoing serious incidents; why, in a hospital for potentially suicidal patients, was access to the roof even possible; and why wasn’t it safe for patients already after a number of earlier ‘wake-up calls’. It went on to say:
“We expect this announcement to attract some media attention over the next few days. Whilst I know this is disappointing, I want to assure you that we are continuing our work to improve our relationships with the media and achieve more balanced coverage.”
Surprise, surprise! Does Southern Health’s overstaffed (and probably overpaid) Department of Spin not realise that the Trust’s relationship with the media will only improve with (amongst other things):
- A major reduction in the number of serious incidents.
- Proper accountability for previous serious incidents.
- Major ‘surgery’ to the Board of Directors and Council of Governors.
- Openness and transparency.
8 March 2017: Winchester Coroner’s Court.
Inquest into the death of Jackie O’Neill.
Alarming similarities to the death of Marion Munns: no robust care plan in place and no response to crisis call just before 5pm.
On this occasion, the deceased herself had called the crisis team talking of suicidal feelings but was told just to take a diazepam and have a cup of tea. Later, she called 999 and two paramedics attended: they took great care in calming her but even they could not contact the crisis team. She fell to her death shortly thereafter.
Unbelievably, Southern Health’s ‘witness’ was a hapless Consultant Psychiatrist, who had never even met Jackie, armed only with a copy of an internal investigation report – we all know what these are like – but even that was redacted. So when the Coroner or family members asked legitimate questions (especially names of Southern Health personnel) he could legitimately answer that he didn’t know. And the Coroner didn’t even challenge it.
Clearly family members, many of whom had travelled a long distance, were distraught at not learning the names of those responsible for the ‘care’ of their loved-ones. So much for SH improving the treatment of bereaved families: SH showed contempt for the family and, in our opinion, for the Court.
The Coroner concluded that there was not an adequately robust care plan in place but despite this (and the unavailability of the Crisis Team), he did not offer to write a Regulation 28 ‘Prevention of Future Death’ Report. This is not without irony: Irwin Mitchell, solicitors acting for the family at the Marion Munns Inquest, confirm:
“The Coroner stopped short of writing a regulation 28 letter demanding improvements saying it is clear that care and delivery issues have had a profound effect on the team and Trust and that this incident had become a wake-up call to them with steps being taken to address shortcomings.”
The Coroner at both Inquests? Graeme Short.
Two deaths with the same shortcomings – and still no regulation 28 report. So Mr Short, how many wake up calls does Southern Health need?
9 March 2017:
By coincidence, the reopening of Melbury Lodge and two classic goofs:
1. Having said three days earlier that they wish to improve relationships with the media, Southern Health gives exclusivity to ITV Meridian, ignoring the BBC and print media!
2. Director, referring the ‘hapless’ Consultant and the lack of other staff at the Jackie O’Neill Inquest: “He was happy about it.” So, that’s alright then: don’t worry about justice or the family.
And a bevy of Spin Doctors to take care of one media organisation and a few guests.