Kangaroo Court

14528651 - illustration of a kangaroo in cage and wooden board


A mock court in which the principles of law and justice are disregarded or perverted. In such cases, one party has already been deemed guilty/innocent and the other has little or no opportunity to question the verdict. 


On a recent inspection, Care Quality Commission Inspectors allegedly concluded that Southern Health’s Complaints Procedures have improved. This is a great mystery as its Complaints, Concerns and Compliments Procedure is unchanged since August 2016.

Appendix 10 of the Procedure (ACTION CARD for the Investigator) is revealing . Brief extracts from the, “Suggested methodology for investigating the complaint” [abbreviated]:

  • Follow the terms of reference….
  • When you have spoken to or met the complainant….
  • Order the critical records….
  • Review any policies, local procedures and national guidance.

There is no reference to the complainant agreeing the Terms of Reference or having an opportunity to check the ‘critical records’ for completeness and accuracy. 

Then, after several more stages involving staff, experts etc., the investigator draws conclusions without any further involvement of the complainant, until finally:

  • Make sure any staff involved have sight of your investigation [report] and final response letter and an opportunity to comment on these.
  • Obtain sign off/authorisation from the commissioning manager prior to submitting your investigation and response to the Customer Experience Advisor.
  • The final response is signed by the Chief Executive.

Read Appendix 10 in full here→

The ‘Action Card’ bears no resemblance to official guidance¹. A fair process allows complainants to be involved at every stage, in particular, towards the end:

“Once you [the investigator] have all the evidence, you can review it to identify all points of agreement and disagreement. It can be useful to summarise these for everyone concerned [bold added].

“It can be very helpful to the process and constructive to issue a statement of agreement early on. This lets all parties know that there is a basis of agreement to build on. This then allows all attention and resources to be focused on the areas of outstanding disagreement [bold added].

“The investigator normally works through all the points of contention until they have reached a considered view on every aspect of the complaint.”

And as final step, the official guidance¹ makes clear [emphasis added]:

“Give both parties the chance to give feedback.

Before the report is finalised, everyone involved should have the chance to give you their views on what you have said. It is important to correct any factual inaccuracies before publication.

If you change the report in any major way, remember to let all the parties know and give them a chance to comment before the final report is issued.”

The Care Quality Commission cannot claim that Southern Health has improved its complaints process recently. In a meeting last month with two long-standing critics of the Trust, the Interim CEO confirmed that complainants would not, in all cases, see a draft investigation report or final letter or be given an opportunity to comment on them.

Why has the Care Quality Commission not compared Southern Health’s procedures with the official guidance¹, details of which are below with links to the full documents? 

In short, Southern Health’s complaints process is that of a Kangaroo Court.

13931038 - kangaroo border around white copy space


Southern Health has no defence for biased procedures. The Department of Health wrote to all NHS CEOs introducing guidance issued pursuant to The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009. It was effective from 1st April 2009.

It established a single approach to dealing with complaints and encouraged a culture to seek and use people’s experiences to make services more effective, personal and safe. 

The guides ‘Listening, Responding, Improving’ and ‘The Quick Guide to Customer Carehelped complaints professionals work with colleagues to make their organisations better at listening, responding and learning from people’s experiences. Additional advice sheets for complaints professionals were also produced covering: investigating complaints, joint complaints that involve more than one organisation and dealing with serious complaints that have safety implications. 

The ultimate irony is that, in ‘Listening, Responding, Improving’, Gemma Seymour, Consumer Experience Development Manager for Hampshire Partnership Trust (which morphed into Southern Health with Gemma in a similar position) writes inter alia:

“You need to listen and let them tell their own story, in their own time. Doing this helps me to establish the facts, which I always check with the complainant to ensure they are correct. I try to make things as easy as possible.

“People also appreciate being given as much of a say as possible. If someone wants their concerns investigated, we involve them in putting together the plan of action.

“The fundamental point is that when you listen, involve and engage people, it makes it much easier to sort out the problem to everyone’s satisfaction.”

42603567 - a cartoon illustration of a sinister looking little kangaroo.

So Gemma contributed to ‘Listening, Responding, Improving’ but then ignored it – or Southern Health (Katrina Percy) prevented her from implementing it. 



One has to ask, if Southern Health had adopted a fair and transparent complaints process on its formation (2011) rather than turn a blind eye to official guidance,  would its services have been more effective and safe?


Epilepsy Rage 2

4559220 - short sighted man needs binoculars to read his book

Director reading Strategic Risk Assessment


On 29 April 2017, we identified five ‘learning opportunities’ in epilepsy, from which Southern Health failed to learn. The ‘learning’ continues … or does it?

First, a simple eye test. Body text in Strategic Risk Assessments is CIDFont+F1, size 4.




Having spent so much time reading Southern Health’s ‘mouse print’ – see previous post –  your scribe decided it was time to visit his optician.  Now try this test:

Font Size4

This image is CIDFont+F1, sizes: 4 to 14 in 2pt steps. Which can you read comfortably?


Optician astonished that NHS is producing important documents in font size 4. There is no statutory limit but guidelines indicate that print should be legible to someone with normal eyesight, or with glasses, which correct to normal. 4 is the lowest possible limit.

In short, a good, comfortable font size is necessary for readable text. This rule is old news but clearly not for Southern Health – unless they don’t want people to read it.


Following the Care Quality Commission’s decision on 6 March 2017 to prosecute Southern Health for an incident in December 2015, the BBC has reported the Health and Safety Executive’s decision to prosecute the Trust under Section 3 of the Health and Safety Act in relation to the ‘preventable death‘ of Connor Sparrowhawk. Read more here and here. A ‘bitter-sweet moment‘, one might think, for his mother Dr Sara Ryan – who has fought for justice for four years with formidable dedication and energy. 

11763603 - what can i do? picture about regret

What can I do? I’m just a Director?

Or it might have been a learning opportunity if Southern Health had not responded with its usual crass comments and non-apology.

The ‘apology’ was part of a statement Southern Health was sending to journalists!



They didn’t get in touch with Connor’s family to say sorry. They got in touch with the press. A purely bitter moment. Read more on Sara’s distressing blog→


It was alleged at an Inquest into the death of Sasha Taylor (a known epileptic) that a Consultant Psychiatrist had increased the dosage of Olanzapine, an antipsychotic drug, during a telephone conversation to higher than the recommended maximum guidelines. Amongst the side-effects of Olanzapine are seizures – with a specific recommendation:

“Tell your doctor or pharmacist if you have any medical conditions, especially … if you have a history of seizures.”

It makes clear also that there are a number of other drugs that, if used in conjunction with Olanzapine, will increase the risk of side-effects. It is alleged that Sasha was also taking Amisulpride, which has a precautionary warning on epilepsy too, and anti-depressants, which are known to lower the threshold for seizures.

The Consultant said he wanted to lower Sasha’s medication but, in order to do this, he had to briefly raise the level of Olanzapine! We bow to his professional expertise but this offends common sense.

Senior Coroner Grahame Short recorded a verdict of a drugs-related death and said:

“It is worrying for us to learn that these high levels of anti-psychotic drugs, which can have serious side effects, were not monitored over 12 months.”

Naturally, Southern Health responded with the usual platitudes. Clinical Director, Professor David Kingdon said:

“We have carried out our own internal investigation and made a number of improvements to the way we support people on higher doses of medication.

“For example, all our teams now have a nominated physical health lead to monitor the physiological effects of psychiatric mediation, and a review of patients receiving high-dose therapy now takes place at every clinical team meeting.”

Oh really, Professor Kingdon! After dishing out a mountain of drugs (often justifiably) for treating psychosis, schizophrenia, depression etc., many of which have very serious side-effects, Southern Health still didn’t monitor patients’ physical health properly four years after its formation … and the percentage of trained staff is unknown to this day.

15413127 - angry doctor holding telephone

And this is not the first ‘distance diagnosis’ – on 8 March 2017 Coroner Grahame Short heard of an outpatient talking of suicidal feelings but being told by phone just to take a diazepam and have a cup of tea – shortly before falling to her death: read more→.


And in 2013, Dr  ‘Mystic Meg Lesley’ Stevens, then Clinical Director, Mental Health Division, used psychic powers to diagnose a patient she had never met or spoken too – even by phone.

And now? We will not use images of barely readable text again but the Trust’s Strategic Risk Assessments for physical health training for November 2016 and April 2017 show:

“New Physical Training programme available for all staff: Attendance % not reported. Course content and attendance recording being reviewed.

“Board Reporting: Attendance accurately not reported.”

Back to School


And who was successively Clinical Director, Mental Health & Learning Disability Director and Medical Director during this time – Dr Lesley Stevens when will she join the seven