Long Ol’ Dusty Road

Badwater road Death Valley National Park CaliforniaAlthough we have seen little evidence of improvement at Southern Health NHS Foundation Trust, when we wrote the last articlelittle did we know that the long, long road to transformation had hardly started.

We quote text messages from third parties commenting on the evidence given by senior Trust leaders on 1 April – newcomers to the saga might have wondered if they were April Fool jokes!

“5 years on from Mazars and they are now looking at the [Serious Incident] investigation template. She admits the clinicians did not co-operate with investigations and could not see the point of them. They were too busy!!!!! 5 years on and now developing leaflets [for service users, families and carers]!!!”

We remind readers of two key issues in the Executive Summary [14,15] of the Mazars Review [January 2016]: 

“Despite the Board being informed on a number of occasions, including in representation from Coroners, that the quality of the SIRI¹ reporting processes and standard of investigation was inadequate, no effective action was taken to improve investigations during the review period.”

“There was no effective systematic management and oversight of the reporting of deaths and the investigations that follow – it is reasonable to expect the Trust to properly review the need for a further investigation into all deaths when staff have been sufficiently concerned about something which they have then reported to their incident management system.”

So (including Interims) four Chairs, four CEOs and three Medical Directors later and the Trust is still only, “Looking at” the investigation template and producing a leaflet to explain the process to patients, families and carers. One hopes the Panel will grasp the significance of this statement. Who is going to be held accountable? 

One wonders what the Care[less] Quality Commission, NHS [Un]improvement and West Hampshire Clinical Commissioning Group have been doing during this time.

During the week, there was further compelling evidence of the innate bias of the investigation in favour of Southern Health. For example:

  1. The week started with a tirade by Mr Nigel Pascoe baldly asserting that a Southern Health staffmember had been bullied horrendously using Twitter©, text messages and telephone calls. Whilst such conduct cannot be condoned, his silence about the gaslighting and bullying of the bereaved families and other potential witnesses, which led to their withdrawal from the process, is notable. Shaun Lintern of ‘The Independent‘ gives a balanced view here. 
  2. A second incident of a Southern Health executive, who could not make her written evidence available to the public because it contained senstive information – again one rule for Southern Health and another for service users, families, carers and the public. Dr Susie Carmen did the same earlier in the process; see here→.
  3. This week’s ‘score’ – 16.75 hours of hearings, of which 15.5hrs were dedicated to staff and only 1.25hrs to a family member/carer.
  4. Having referred to the Mazars Review again, the true independence of its Review team [page 2] is in stark contrast to the Public Investigation, with its panel heavy with NHS management. 

A Twitter© feed by a current Southern Health service user and potential witness at the Pascoe Hearing has come to light. It demonstrates bullying of current service users too. Starting with the earliest [bold added]:

“Southern_NHSFT why why do you distress suffering despairing people more and more? You are supposed to be improving. Doesn’t say much for all the money you wasted on quality improvement. There are good people working on the ground but zero confidence in the management.

“Last week was despair all created by @Southern_NHSFT. The final straw was to get a letter telling me not to complain about my care on Twitter, not name people I have never named anyone. I started a suicide note I stopped after a conversation and an email from a senior person.”

“Do you realise @Southern_NHSFT that a person who is suppressed and is not able to speak freely,  it is very damaging to ones mental health. I do not want letters telling me they would file it in their legal department because I complained on twitter.”

“There are some excellent people working for @Southern_NHSFT and have helped me a lot.The head of nursing I spoke to and sent me the apologetic email is one of them and many others. There is something inherently wrong at senior level because all the good caring people leave.”

What has happened to this great big Quality improvement programme which cost a fortune. I don’t see any improvement if anything things have got worse.”

“I have done absolutely nothing today, other than talk on the telephone to nice friends and family. My one wish for tonight is to get some sleep. Please @Southern_NHSFT don’t give me any more sleepless nights with your insensitive and inaccurate letters.”

“I feel very strong about injustice, for the past week it has been a tug of war with @Southern_NHSFT, which has worn me down physically and mentally. Came close to my death. Never win justice with organisations that cover up. Is it worth it?”

“I’m trying to be forgiving and understanding about @Southern_SHFT but I’m not a fool because I suffer with my mental health. I’m at a stage where I feel they wiĺl never change in spite of all the money spent on Quality improvement. What it lacks is transparency and honesty.”

“Cannot get to sleep thinking about the letter I received from @Southern_SHFT Meeting tomorrow,  just hope no more cover ups. I am entitled to say what I feel on any platform if I am not getting the support when I reach out. This letter has set my recovery back so much.

So, with letters to the mentally unwell implying the Trust might instruct theirlearned friends‘ resulting in suicidal thoughts and a relapse, how many service users would risk their care by ‘taking the stand’ at a Public Investigation with the Trust’s senior leaders looking on. 

And whilst on the subject of intimidation, as a relatively junior or new manager at Southern Health, how would you feel about criticising the Trust with the Chair, CEO and other Executive Directors looking on?

A final thought:

With five years delays in implementing change, one has to ask if Southern Health (and the NHS in general) is becoming too reliant on technology, systems and procedures at the expense of culture and human factors. We are reminded of the heroic actions of Captain Kevin Sullivan in saving 315 lives on Qantas Flight 72 after one of the aircraft’s three air-data units sent incorrect information to other systems, resulting in a flight control computer twice commanding the aircraft to nosedive towards the sea. The documentary is available here→

Capt. Sullivan quotes Capt. Chesley Sullenberger, pilot in command of US Airways Flight 1549, which ditched in the Hudson River off Manhattan after both engines were disabled by a bird strike; all 155 people aboard survived.² 


“Technology is no substitute for experience, skill, and judgment.”

The two ‘Sullies’ have a point.

Is technology in the NHS a substitute for experience, skill, judgement, empathy and an open culture?

©  Important Notice:


It has come to our attention that others reporting on Southern Health are culling images from this website without consent. Please see the copyright notice on our home page. We have also found images culled from other websites, including some where the copyright holders are, for example, the BBC, printed media or even the breaved families. 


¹ SIRI – Serious incidents requiring investigation

² ‘Miracle on the Hudson‘ by Chesley B. “Sully” Sullenberger lll with Jeffrey Zaslow (previously published as ‘Highest Duty“) 


1 thought on “Long Ol’ Dusty Road

  1. CRASH has received an anonymous email, which we felt should be added to this article:

    “Subject: Pascoe

    “We have sent this to the panel anonymously.

    “Do you know that the Trust are again devaluing mental health? They have not learnt. From the mistakes of the past with not valuing mental health.

    “If you are brave enough, ask what expertise in mental health will the board have with new medical director. Putting people in charge who don’t understand mental health. The families who have suffered is because of focus of Board being not on mental health, devaluing mental health, they have not learnt.

    “We are clinical mental health staff in the trust who don’t dare to speak up because of consequences.”

    NOTE: We have no way of verifying the source of this email. However, we are not publishing the email address used – to prevent a witchhunt.


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