Brian Rix?

Trousers down

‘King’ of West End farce, actor and impressario Lord Brian Rix¹ is credited as losing his trousers over 12,000 times in 26 years on stage. Previously, we referred to Basil Fawlty but Stage 2 of the Public Investigation into Southern Health NHS Foundation Trust by Mr Nigel Pascoe QC is fast-becoming like a Fawlty-Rix co-production.    

Despite the families’ withdrawal on 29 January 2021 amid allegations of being misled, misrepresented, gaslighted and bullied, NHSE/I issued updated procedures but continued (implictly and explicitly) to include the families in the Terms of Reference (“TORs”) – no doubt desperately hoping they would reengage and to lend credibility to the farce. It met a tart response from the families in a new public statement to the Panel Secretary, Alice Scott: 

“Thank you for your email on 12.02.2021. The following statement from the 5 families addresses this. 

“The families are not prepared to partake in the investigation or work with people and organisations who refused  to honour the agreed terms of reference for stage 1, and who have the audacity to transform a stage 2 public investigation into a kangaroo court designed to showcase improvements to Trust policy at the expense of learning from the deaths of  five very vulnerable people.

“The idea of spending a few more months locked into an exploitative relationship devoid of trust, with people who mock the word independence, reject the integrity of transparency, and circumvent investigations into the deaths  of vulnerable people, will invariably result in further torment, distress  and frustration for all of the  families.  We see no point in resuming participation in a process that has so cruelly and repeatedly denied us any sense of closure and justice for our loved ones.”

It was followed by another public statement:

“It has come to the attention of the families that you issued a revised Procedural Document for the Stage 2 hearing subsequent to our withdrawal from the process. We understand that this document refers to the participation of the families in regard to the hearing / public investigation and we firmly believe this is misleading to witnesses and others who may be participating in the process.

“We are clear in our decision to withdraw and we therefore request that you remove any suggestion of the families’ continued involvement from any communications in connection with the hearing and public investigation.”

In a longer statement available here, CRASH and a recently resigned Public Governor of Southern Health NHS Foundation Trust withdrew their evidence and two complainants explained why they had not even registered as potential witnesses. We highlighted more omissions in the TORs, especially consideration of the Trusts’ leadership, governance, and culture, and (of course!) NHSE/I’s failings and actions (including failure to address alleged witness intimidation), none of which will be considered by the Investigation. 

But ‘Health Service Journal‘ this week published two articles about the ‘Learning from Deaths‘ project, which aimed to standardise and improve the way acute, mental health and community Trusts identify, report, review, investigate and learn from deaths, and engage with bereaved families and carers:

In 2017, the National Quality Board (“NQB”) published new Guidance on the subject. 

Ruth May - Stay Home this Easter

And who is on the NQB Board – Ruth May, Chief Nursing Officer, who is entirely responsible for guaranteeing that this Fawlty/Rix coproduction will not deliver justice to five bereaved families and that the NHS will not learn from their experience.


Beautiful woman in glamorous dress napping in her bed after part

How do these people sleep at night?

Soundly, we suspect – in full knowledge that their jobs are secure. Reminds us of the old Australian Aboriginal adage:

Mouth one way, belly ‘nother way.



karl marlowe - Spin Doctor


Medical Director, Karl ‘Where’s my Spin Doctor’ Marlowe resigns just before start of Pascoe Investigation. Off to join his mate, Dr Broughton at Oxford Health NHS Foundation Trust.



¹ In Memoriam The Right Honourable The Lord Rix CBE DL 

This process may be akin to a Brian Rix farce but it would mortify him.


His first daughter, was diagnosed with Down’s syndrome. Then, there was no welfare support, little education and only a Victorian era, run-down hospital for affected children. He campaigned and fund-raised tirelessly for charities.

Basil Fawlty?

Time to Fact Check Dispel Rumors Find Truth Clock 3d Illustration

We planned to fact-check Mr Nigel Pascoe QC’s Stage 1 report, having found a glaring error. However, it has become more important to fact-check the process for Stage 2, which is fast becoming Fawlty-esque. So, we will update the story with news links; correct the error in the Stage 1 report; and finally fact-check the procedures for Stage 2.

‘Nursing Times’CNO replaced as senior responsible officer in Southern Health inquiry

Another courageous report on Chief Nursing Officer for England, Ruth May – now standing down as Senior Responsible Officer (“SRO”) for Stage 2. Did thIs follow the robust criticism in the ‘Nursing Times’ first report? Surely not!  Free access to the Nursing Times here→

‘Daily Echo’ – ‘Bereaved families ‘lost trust’ in NHS

Valerie Walsh – a Southern Heath employee compares her treatment for mental health with her stay in an acute hosital. Her Tweets from 17 September to 3 October 2020 are telling. We met Val in 2016, just after she resigned from Southern Health to protect health – yet she still had the dedication to rejoin. Read more here→ and here→.

Pascoe Stage 1 Report – Fact Check – The Triangle of Care

On p.175 of the Report, Southern Heatlh NHS Foundation Trust claims:

“Triangle of Care, a national initiative, launched in 2010 by the Carers Trust for mental health and inpatient services was re-launched in Adult Mental Health services (2018).”

This is wrong: CRASH questioned the Trust’s use of the Triangle of Care logo in November 2019. On 17 November 2019, a senior official from Carers’ Trust replied:

“I have looked into the issue you raised and I can confirm that Southern Health NHS Foundation Trust have applied to become a member of the Triangle of Care community.  They are currently undertaking level 1 which is focused on inpatient services. They have until mid-July  2020 to complete this phase which will then be reviewed by a team who have gone through the process and are outside of the South West to ensure independence.  The review team will include a carer. If they are successful they can go to level 2 which focuses on community and crisis services.

“I have also been in touch with the Trust and asked them to take out the two stars from the Triangle of Care logo which they have done. They have apologised and assured me this was a genuine mistake by the person who put it on the website because they had insufficient knowledge of the scheme.”

So the Trust told the Panel that the scheme had been re-launched in 2018 but one year later the Trust had not been approved; was misusing the logo; and had up to another 6 months to complete the approval process. I believe that the ‘re-‘ in ‘re-launch’ is misleading per se

It is interesting to note the Trust’s excuse that it was a, “Genuine mistake.” In November 2019, Mr Pascoe’s Stage 1 Report was still in draft form. There cannot be two, “Genuine mistakes” so Trust Board Members could have rectified this ‘mistake’. 

Stage 2 – Fact Check  

It is evident that even the procedures for Stage 2 have not been fact-checked. For example:

1. When a potential witness asked the new SRO Aidan Fowler for a copy of the Mental Health Act 2005, which was quoted in the papers, he supplied a link to the Mental Capacity Act 2005. The Mental Health Act 2005 does not exist. Might this error result from his ‘trade’ – a Consultant Colorectal Surgeon? At least, if stress from this process causes anyone to suffer severe haemorrhoids and constipation, perhaps he can help!  

2. In ‘The Daily Echo’ on 12 February, Medical Director Dr Karl Marlowe is quoted: 

“We encourage anybody who wants to share their experience to contact the Panel directly.”

Funny that – the deadline was 10a.m. on 11 February!

3.  Originally, those meeting the 11 February deadline were to be informed on 12 February if the Panel required a full written with statement and evidence. Then, witnesses would have until 17 February (two working) days to submit it. However, on 12 February, we learned that the deadline had been extended until 4pm on 22 February!

Great, you might think! However, how many potential witnesses didn’t register originally knowing believing they would have only two working days to submit full statements and evidence. The fragrant Ruth ‘Stay Home This Easter’ May was aware of concerns about unrealistic timescales months ago.

4. There is a mystery over the status of the new SRO, Aidan Fowler, too. Whilst using NHS notepaper for this purpose: 

“Since March 2020 he has been on secondment to the Office of the Chief Medical Officer, Professor Chris Whitty” [source:]

Of course, Professor Whitty is currently committed to COVID-19, aided by his three Deputy Chief Medical Officers, two of whom we have seen at Number 10 Briefings – the ever-impressive Professor Jonathan Van-Tam, along with Dr Jenny Harries. Whilst Aidan Fowler, who clearly is engaged in Covid work too – even writing articles for the press and being named on Professor Whitty’s profile.


Who should be more concerned?

The public for the risk of distracting a Deputy CMO from Covid or the bereaved families for the risk of Covid distracting the SRO?

More on Mr Basil Aidan Fowler to come.



Red words Warning Gaslighting detected

On 9 February 2020 we reported the result of an ‘independent’ report on Southern Health NHS Foundation Trust under the headline:

Truly deplorable and unacceptable saga

In his report (here) Mr Nigel Pascoe QC recommended a two-part Public Investigation –firstly into the death of one patient and secondly into the Trust’s current performance in limited respects.

It pains us to report that, despite the families struggling for almost 12 months to negotiate Terms of Reference (“TORs”) and Procedures with Ruth May, Chief Nursing Officer for England (“CNO”, also a director of NHSE/I) and Mr Pascoe, they refused to listen.

Describing the investigation as a charade, the families allege that they had been misled, misrepresented, gaslighted and bullied. The full, unabridged Family Statement is here→.

Read and weep – CRASH has known these families since 2016. They have been struggling for justice for up to 10 years and have been brutally shut down at every stage.

blue blowtorch

We have known of this for over a week but, from experience, it is more effective to give national media ‘first dibs’, not scoop them!

It also make life easier for us. Readers can just follow these useful links:


BBC NATIONAL – ‘Southern Health: Bereaved families ‘gaslighted and bullied‘ by NHS by Michael Buchanan, who has doggedly followed the story since 2016. In addition, BBC South Today has covered the “Charade” already on two separate occasions, fronted by the excellent James Ingham, who reported on the Inquest into the death of Ellie Brabant. It’s was also on BBC radio and even CEEFAX.    

‘NURSING TIMES’ – ‘Families ‘lost all trust’ in inquiry commissioned by CNO‘: a fearless article considering it relates to the Chief Nursing Officer for England, Ruth May. 

FREE ACCESS: you can register for a week’s free access to ‘Nursing Times‘: that way you can see the hurtful comments made about the families too, especially by NHSE/I (family blame) and (to a lesser extent), Southern Health’s Medical Director, Dr Karl Marlowe

TWITTER©: there is considerable activity in the Twittersphere too: follow the links on the names, (You can access these threads without registering with Twitter©).     

  • Rebecca Thomas – senior reporter, Health Service Journal (“HSJ”). 
  • George Juliantireless supporter of improvements for those with learning difficulties, who we first met in 2016 as supporter of Dr Sara Ryan.a mother of ‘Laughing Boy’. Starting with a recap of the Connor Sparrowhawk case, this is a long thread but well worth a read. WELL DONE George!
  • Alison Moore – another HSJ reporter scroll down the page to 3 February 2021.
  • Dr Sara Ryan – mother of ‘Laughing Boy‘ – Sara has been twittering for a long time (111.9K Tweets + so, as they are in reverse date order, here’s her first reaction:  

    Sara's Tweet (reduced)

    Well done Ruth May and Southern Health – you’ve even succeeded upsetting a bereaved family, who’s not even involved in this investigation. 

The TORs and Procedures for the Public Investigation are available here if service users, carers and families wish to participate. Beware of the tight deadlines; restrictions on what you can say; and practical and technical requirements. We do not wish to see families and service users drawn into what appears to be a virtue signalling exercise.

If having read this post, the TORs and the procedures, you wish to express your views on the process. You can email Ruth May here and Mr Pascoe QC here, as well as leaving comments below.

In memoriam:

Edward Hartley and Connor Sparrowhawk, two much-loved young men lost far too early:

Edward 2


Edward      © Ian Hartley



Connor © Dr Sara Ryan