This week, what a family member described as a, “not-so independent investigation” into Southern Health NHS Foundation Trust demonstrated that complainants (‘the little people’), however well-qualified, are crushed by what some refer to as a totalitarian state.
Again, there is no recording of the hearing in the public domain so we must be careful in what we report. However, journalists use shorthand so we can rely more on media reports.
Now we have to see if they will be honoured.
Mr Pascoe issued a warning over attempts to intimidate witnesses giving evidence:
“Any attempts by any person, anywhere, to dissuade a witness from giving evidence, in criminal or civil proceedings, may amount to an attempt to pervert the course of justice.¹”
And added that the Panel would, “Not hesitate to act” on attempts to intimidate witnesses.
In our opinion, a charge of Misconduct in Public Office² might allow more flexibility because the offence is confined to public office holders and is committed when the office holder acts (or fails to act) in a way that constitutes a breach of the duties of that office.
Paula Hull issued what amounted to an open invitation to all dissatisfied complaints to contact her to discuss their outstanding concerns.
Ironically, she also stressed that Terms of Reference (“TORs”) for investigations must be agreed with complainants. Exactly what NHS Improvement failed to do in respect of the Pascoe investigation!
Fact-checking – Triangle of Care:
In the Stage 1 Report, we identified a mis-statement about the Triangle of Care, detailed here. Yet, this week a Southern Health witness repeated the same terminological inexactitude that the Triangle of Care was launched in 2018, despite the Trust’s admission in November 2019 that this was wrong. The excuse was that it was a “genuine mistake“. That’s now three, “Genuine mistakes.” This is fact – we don’t need a recording.
Alarmingly, CRASH wrote to Mr Pascoe on 28 January 2021 attaching emails from the Triangle of Care, copyright owner. Yet still, the Panel did not challenge the witness.
Balance of Evidence:
In three days scheduled for ‘Complaints Handling’, 10.5 hours were allowed for witnesses from Southern Health and their supporters, West Hampshire Clinical Commissioning Group but only 2.5 hours for service users. Res Ipsa Loquitur.
Equally, the procedures for the Hearing specified that, if 3rd parties names are used in statements, they will be anonymised or redacted and not referred to during the public hearing. Any breach would lead to a warning by the Chair and potentially the Panel might refuse to hear further evidence. Yet, Dr Susie Carmen produced unredacted evidence, which she could not show to the public – and the Panel went along with her.
Yet again, one rule for service users and carers and another role for Trust witnesses. As evidence had to be submitted in advance, why did the Panel not instruct Dr Carmen to redact it?
Service User Witness
All credit to carer, Sue Heselton – a bereaved mother not included in the family group. We could hear the distress in her voice. She started by endorsing Mr Matt White’s suggestions last week and went on to make the following observations (from contemporaneous notes):
- People are still very unhappy not just in the past: she knows unhappy patients now.
- The Trust should make it easier to complain avoiding the need to repeat complaints.
- She has been blocked from making complaints and the Trust insists that she uses a generic address. It stops people being heard.
- Investigations need to be independent, not be controlled by SH.
- Investigators need legal training, have a good understanding, and be confident enough to ask for anything.
- She claimed to have watched ward staff persuading inpatients not to make a complaint with such statements as, “Oh you don’t want to make a complaint, so you dear?”
- Staff need kindness and compassion.
- Southern Health is a top heavy organisation!
We commented earlier that, despite witnesses attesting they would tell the truth, there was no means of checking if they were doing so. However, this time the Panel DID know about the discrepancy relating to the Triangle of Care (above) but failed to challenge it.
Again, witnesses made various assertions, which were not evidence based. None appeared to have a grasp of their brief and some gave the impression they didn’t want to be there. We heard some hypocrtical statements – effectively summed up as a large dose of, “Do as I Say (Not as I Do)“³
Put another way, I believe that progress made by Southern Health is not how they sought to characterise it. For example:
Dr David Hicks, Non-Executive Director of the Trust claimed that its complaints handling system was, “Very inclusive“, and “Very patient centred.” Dr Hicks described Mr Pascoe’s [Stage 1] report as, “Harrowing reading“, and said the, “Memory” of the patients was a, “Strong implement (sic) to improve things.” Read more here→
Dr Hicks, if memories were so harrowing and a strong incentive to improve, why did you:
- Not hold the Trust’s Board to account after the then-Chief Executive Officer brutally ended co-operation with the families in December 2018?
- Not ensure the current CEO re-engaged with them?
- Take an exclusive and non-complainant centred approach when commissioning an investigation yourself?
Paula Hull, made assertions that CRASH does not recognise from personal experience. Some of our questions remain unanswered after almost 10 years, despite a reminder being recorded at a post-2016 Board Meeting.
She emphasised the importance of TORs for investigations being agreed with complainants. CRASH knows that the Trust is prone not to do so – especially if the complaint relates to senior leaders. She also claimed that, when complainants disagree, they can add comments to investigation reports. That’s news to CRASH too.
Dr Susie Carmen, Consultant Psychiatrist said there had since been a, “Genuine culture shift from the top of the organisation” and asserted that it was normally new and junior consultants, who don’t get things right on family involvement. The families of Ellie Brabant, Joey Duarte, Luke Keen would disagree. Another bereaved family member disagreed too:
“It is indefensible that she blames the lack of liaison with families on new psychiatrists who may not know the guidance properly, especially given her educational role at the Trust. The fact is that psychiatrists should know what their responsibilities are and what the guidance states before they commence their work with vulnerable people and their families – we shuold not be scape-goats for these failings whatever their cause.”
And by no means could Ellie, Joey or Luke’s Consultants could be considered junior.
Truth Commission – as well as the families’ pleas for a genuinely independent inquiry, perhaps a Truth Commission is required too.
Jo Deering, a much-loved lady lost too early, and whose family still await justice after almost 10 years.
© Dr Maureen Rickman
² Ditto – Misconduct in Public Office.