Candle in the Wind

two candles with dark background

Dr Bill Kirkup CBE, whose evidence to the Pascoe Investigation into Southern Health NHS Foundation Trust was reported here, was followed by two more equally authoritatve and credible independent witnesses, Dr Josephine Ocloo and Keith Conradi.


Dr Jospehine Ocloo

Senior Researcher & Health Foundation Improvement Science Fellow at King’s College, London, Dr Ocloo became involved in patient safety after her daughter died following a medical failure. 

This gives her a high profile role as a patient representative and patient safety researcher. She completed a PhD in 2008 on medical harm from the viewpoint of those directly affected by safety incidents. She emphasised the, “Awful grief” experienced by bereaved families, subsequent betrayal by the NHS, causing, “Further grief.” She described this as,

The dark side of the NHS” [adding]

“This will keep happening until it the NHS is fatally wounded.”

Will the Panel identify the irony in Dr Ocloo’s comments? The families’ original withdrawal statement and their refusal to re-engage, demonstrate that the Pascoe Investigation is yet another act of betrayal – this time by NHSEngland/Improvement. Read more here→

house sinking with a downward arrow on background, verticalDr Ocloo used the analogy, ‘You can’t build anything on sand.’ The foundations must be right.

We summarise some of her insightful views, as noted:

  • The Duty of Candour will not work without remedying the root cause – a closed culture with no transparency.
  • Defensiveness and unwillingness to ‘own up’ prevents openness and transparency too.
  • There is no commitment in the NHS to Article 2 (The Right to Life); families are seen as the problem. Trusts need to own up and settle.
  • There is no commitment to openness and transparency – starting with the leadership.
  • There needs to be the right balance between accountability and learning – this is essential in a democratic society.
  • Trusts are large corporate bodies with many opportunities and resources to cover up their failings.
  • The architecture of governors, non-execututive directors (“NEDs”) and Executive Directors is driving the problem. NEDs often lack true independence; governors have little influence and are unable to challenge effectively.
  • Patient/public engagement has been mooted since 1970. It doesn’t work; it excludes the most vulnerable, including Mental Health and Learning Disability patients.
  • Complaints are not investigated independently: the PHSO is ineffectual. Families are let down by everyone; excluded from investigations; and treated, “Brutally.” 
  • Recent and old cases are remarkably similar.
  • There should be statutory complaints regulations with investigators completely and truly independent of the Trust, including laypeople from outside the NHS.
  • There needs to be a cultural shift in Regulatory bodies. All are perceived by the public as ineffective – endless criticisms of them are not addressed.
  • Laypeople are not involved sufficiently in all areas the NHS, including investigations. 
  • Service users, families and carers have no-one to turn to for robust assistance. 
  • Has heard of a ‘cultural shift’ but there is no genuine contrition. Culture can only be judged by service users/families – their perception is key. 
  • Harmed patients are not considered important but trusts cannot learn without them. Some families are prepared to ‘cross the barrier’. 
  • In 2016, circa. 80 bereaved family members attended a meeting about a proposed Learning Disabilities Mortality Review (LeDeR) Programme¹. There is no evidence of any recommendations being implemented; 5 years later, “LeDer has stalled.”
  • In 2017, the Care Quality Commission said there was no organisation running complaints systems properly: doesn’t think there’s been much progress since. 
  • Even she [a patient representative and patient safety researcher] struggles to be involved at a senior level.
  • Ideally investigators of serious incidents should be completely independent of Trusts and the NHS. This should include natural deaths to check nothing is being covered up.
  • Families should have access to legal advice to overcome an imbalance of power. One side has legal and medical experts; grieving families have nothing. 
  • Patient safety issues are not opened out from the Trust. Healthwatch might give public input but have no remit to hold Trusts to account.
  • There may be salvation in Integrated Care Systems if there is family and patient representation.
  • There should be diversity of investigators², including lay voices, and a medical expert.
  • The “Just Culture” currently is geared to staff interests rather than patients/families.
  • It is not a psychologically safe system – ‘the Trust is always right‘. Staff who speak up are gaslighted and treated brutally. 
  • Children, adolescents, and elderly often get missed out. This is little support during investigations – independent advocacy does not work.

Dr Ocloo feels the most fundamental issue is that investigators must tell families: why an incident has occurred; if it was preventable and; who is accountable. She recommended  Trusts should look at the commercial world to learn about investigations. We know many isues at Southern Health remain unresolved – the bereaved families’ issues for example.

She recommended a ‘Truth Commission‘, provided that both parties are willing to engage in good faith – as in the South AfricanTruth and Reconciliation Commission.’

cropped 12010377_s image requested

Keith Conradi 

Chief Inspector of the Air Accident Investigations Branch (“AAIB”) (2010 – 2016), Keith has been a professional pilot for 40 years. He is current Chief Investigator of the Healthcare Safety Investigation Branch (“HSIB”).

Keith made a stark comparison between aviation industry’s attitude to safety incidents and that of the NHS; it became clear when he became founding member of HSIB in 2016.

  • There is evidence that NHS investigations attempt to avoid liability. The AAIB assumes people come in to do a good job and do not to blame individuals for honest mistakes. 
  • There should be a culture balance between a learning culture and accountability. The latter usually is carried out by regulators. 
  • A single regulator Civil Aviation Authorityensures the whole aviation industry meets the highest safety standards. Accountability in the NHS is too complex and fragmented with too many regulators and no straight line of accountability.  
  • International Air Transport Association (“IATA”) is a powerful, unified and experienced voice supporting and promoting the interests of aviation worldwide, and setting overall standards for members. There is nothing similar in healthcare – even in UK.

Notwithstanding the importance of a single national regulator, Keith emphasised that a strong and accountable Board is essential in large Trusts. The most successful are where Board Directors show a keen interest in safety incidents and complaints.

During his time at the AAIB, Keith felt easyJet was the best performer. He credited the CEO, Dame Carolyn McCall, DBE for taking a personal interest in all safety incidents. 

Carolyn-McCallIt is no coincidence that under her leadership easyJet achieved record passenger numbers and record profits. 

In 2013, Flight Global gave Carolyn the Airline Business ‘Airline Strategy Award for Low Cost leadership’.


Who said Lean Management, cost-saving and safety are mutually exclusive terms?

Interestingly, just as the panel asked Dr Kirkup if his experience clouded his judgement of the NHS overall, a Panel member questioned the validity of comparing the aviation and healthcare sectors by claiming that healthcare is far more complicated. 

We beg to disagree – if there is a serious incident involving a Boeing 747, the aircraft (with six million parts), crew, airline, manufacturer, air traffic control, airport, cargo, check-in staff, ground handlers, meteorologists, engineers (and so on ad finitum) all are considered as possible causes. Investigating, for example, deaths by ligature, is simple in comparison.

We summarise some of Keith’s other views, as noted but in no particular order:  

  • Families want a true account of what happened and accountability; they don’t want repeated mistakes. A separate organisation should hold Trusts accountable. 
  • In investingating complaints, a current employee of a Trust cannot be independent. There are huge issues with perception, which are very difficult to overcome.
  • Leadership of the investigation is key – one can be a good leader without being a safety expert. The leader does not have to be from the healthcare sector. 
  • Local investigators need better training. At HSIB, new investigators do 3-weeks’ intensive classroom training before shadowing an experienced investigator. Then, they are allocated to a team but remain accompanied until judged sufficiently competent.
  • Family engagement essentail: every time. It is key to keep them in picture and prvide key information. They know more about the culture of organisation and provide invaluable and insight on improvement. 
  • Families should always get opportunity at face-to-face meetings to comment on draft reports. If they disagree, both views must put both into the report.
  • On Duty of Candour, it is sad there has to be a legal obligation in the NHS: 

  “Honesty and family involvement are essential as human nature.”

  • Overall Compliance with the Duty of Candour is the responsibility of the Board, which should take immediate action on breaches.
  • The HSIB has been a slight improvement in culture but only where it has carried out investigationes. There is talk about a just culture – but only relating to staff safety.
  • An accountable Board is better for local complaints. A health and safety expert should sit on the Board; the CEO should sit on the Trust’s Quality & Saftey Committee; and there should not be so many on the Committee that it dilutes responsibility.
  • The Board should check very early that action plans have been implemented. This cannot be effective if complaints are not taken up to Board level. [Southern Health has just divisionalised complaints, shifting responsibility farther away from the Board.]

Keith described the HSIB’ limitations as a, “Small agency” on a non-statutory basis, with funding of £4.5m and 45 employees. The HSIB is placed in NHSE/I but they have no say in what the HSIB does except, for example in planning, resources, and personnel services. NHSE/I can allocate additional resources for special projects. 

We would that, if NHSE/I allocates HSIB’s funding, they have significant control over what HSIB can achieve. We believe HSIB should be put on an independent statutory basis and allocated significantly increased funding. Keith would not be averse to increasing the HSIB’s role, perhaps with a regional team and a register of trained, accredited independent investigators for Trusts to choose from. CRASH says, “Bring it on!”  

We make no apology for this post being lengthy and staid – the evidence of Dr Kirkup, Dr Ocloo and Keith Conradi is key. It is for the Panel to determine how closely Southern Health meets their requirements and thereby demonstrate its true independence.

In memory of all Southern Health’s patients, whose lives have been lost. We can only hope.

Candle of Hope2

And it seems to me you lived your life
Like a candle in the wind
Never fading with the sunset
When the rain set in
And your footsteps will always fall here
Along England’s greenest hills
Your candle’s burned out long before
Your legend ever will.4


¹ LeDer was the world’s first national review of deaths of people with learning disabilities. Commissioned after the findings of the ‘Confidential Inquiry into premature deaths of people with learning disabilities from 2010-2013’, the Mazars Report on deaths of learning disability and mental health patients under the care of Southern Health Trust re-emphasised the importance of the programme. Read more here→

² Diversity issues at Southern Health are not limited to the 9 protected characteristics. In practice, they engage only with compliant customers and reject those with the knowledge and management expertise to identify improvement opportunities and assist implementation.

³ Elton John, Bernie Taupin [1997] 


“The Dark Side of the NHS”

Socks Eyes

CRASH has experienced serious IT issues. Some suggested that we might have been ‘got at’ but we found no evidence of this. It necessitated a change to our email address

The Pascoe Investigation re-started dramatically on 6 April 2021. Nick Ralls¹, an NHS accredited hypnotherapist, whose son has been a service user of Southern Health NHS Foundation Trust and its predecessor body for over 20 years, alleged that his experience of, “Engagement” with the Trust’s Board had, “Got worse over time“. He could not see, “Any improvement” in the complaints process, adding:

“I don’t see a cultural change…. It seems to be more problematic as time goes on, the way the complaints are handled.”

A full report of Nick’s evidence is on the BBC website here→. Others share his view.

Next were two witnesses relatively supportive of Southern Health (unsurprisingly ‘NHS-lifers’). The Chair of Healthwatch Hampshire, Anne Smith, appeared ill-informed. Dr Vaughan Lewis, S.E. Regional Medical Director, NHS England, displayed little knowledge of Quality Improvement. He admitted lack of expertise in mental health and learning difficulties and that these subjects are normally addressed by staff 1/2 steps below him. Where is the parity of esteem – enshrined in law by the Health and Social Care Act 2012?

Bizarrly, we heard from retired Judges – His Honour Judge Neil Butter CBE (rtd. 2001) and His Honour Judge Keith Cutler CBE (rtd. 2021). The former asserted that retired judges should not chair serious incident investigations (“Judges do not do empathy“) whilst the latter said the opposite because judges have (“Empty brains“). In short, they cancelled eachother out – Judges would require ‘expert’ advisors too, thereby racking up costs. 

We then heard three truly independent, authoritative witnesses, whose evidence was extensive, compelling and very well-informed. 

Dr Bill Kirkup CBE


A fearless veteran of many investigations Dr Kirkup led inquiries into Morecambe Bay maternity services and Jimmy Savile’s involvement at Broadmoor. He was a Panel Member of the inquiry into the deaths at Gosport War Memorial Hospital.


Dr Kirkup asserted that Trusts need to address five issues in investigating incidents: 

  1. They should not adopt a defensive mindset or challenge findings made against it. 
  2. Effective leadership: especially when things go wrong. Public must trust the leaders.
  3. Breakdown in clinical relationships – between those with different clinical backgrounds. Once embedded, professional jealousy is hard to identify.
  4. Clinicians do not own up when things go wrong, especially if someone has died. They look for reasons to deny liability. There is a subculture of invincibility. 
  5. Disconnect between senior leadership and front-line workers, which lead to ineffective clinical governance.

In rating complaints handling, Dr Kirkup rated some Trusts as very good; 70% adequate; and 10% incomprehensibly bad. 10% do not learn from incidents. He referred to the ‘We can’t make a mistake’ culture still prevalent amongst doctors and believes that overcoming the, ‘Subculture of impossible expectations’ must begin with doctors’ training. However, the General Medical Council says it has no room on the syllabus.

When asked how the 10% could be identified and improved, he referred inter alia to the following requirements. 

50027334 - learn and lead business concept


  • The Chief Executive Officer (“CEO”) and Directors must be closely engaged in patient safety issues and complaints.


  • Many spend too long looking at high level figures, which do not tell the whole story.
  • Many do not check learning such as by talking to people, including service users. 
  • Hierarchical systems and ineffective teamworking are a feature of poor leadership.
  • Boards often do not have the ability to recognise what’s go on – directors should go out talk and visit places. Bad ones shut themselves behind a key card!
  • Good leaders admit when they need professional help; others fool themselves and don’t tell anyone.
  • There must be accountability for change: without improvement, the leaders must go.
  • Current assessment of leadership by regulators is not working as well as it should.
  • Changing deep-seated attitudes and culture depends on leadership. 
  • Does it need a change of leadership to change culture? Very difficult to change culture unless the current leadership admits to the Trust’s errors.
  • A change in culture often needs a change in leadership. 
  • Only service users, carers and families can attest to changing culture.

Duty of Candour

  • Just be open and honest – there should be no need for a legal duty.
  • There must be full, immediate disclosure of evidence – families and patients must be involved throughout to avoid loss of trust. Those who recognise most incidents often the safest. If the process is not inclusive things can be missed.
  • Subculture of impossible expectations and clinical denial – “We can not make a mistake culture” still prevalent.  
  • Needs a process and audits to ensure learning is implemented. 
  • Clinicians should have proper meetings with customers, not ‘edge of the bed’ talks; admit to their errors; and welcome customer involvement. 

Triangle of Care 6Customer Involvement 

Lack of communication with families stems from clinicians not accepting that things go wrong: the reach for reputational management starts at clinical level. They do not want to sit down with people and listen.


Complaints & Investigations

  • Response to complaints is not good, often dismissive/hostile. ‘Get rid of them a.s.a.p.’ – they are not linked to clinical governance and can become confrontational.
  • The gold standard is that complaining should be easy. He emphasised progress made in the commercial sector in this respect.  
  • People should not be looking at their own incidents – will not get best learning.
  • Independence of investigators must be proportional – they can be part of same Trust but not the same team. In more complex serious incidents, it is wholly wrong that Trust investigates itself; it must be wholly independent.
  • Investigations should not be led by clinicians – they are not objective. Bishop James Jones is a good example of an expert in leading investigations. Educational background is immaterial – they need to understand the process. 
  • Families should be involved throughout: meetings should be informal with  constructive dialogue, avoiding Trusts being told by lawyers not to answer questions.
  • When families require legal assistance, it should be provided.
  • There is no criteria for the commissioning of an independent inquiry – should include deaths or systemic failings. Dr Kirkup found a death where a simple check list was produced – 9 months later, it happened again.
  • Must involve relatives and/or customers in investigations. Investigators should be open with people, not treat them as witnesses. 

Medical Records

  • Medical records often show events as they were ‘thought to happen’; they are too ‘clinical.’ This needs to be remedied. 

48375735 - learning never ends message on the card shown by a man

Learning & Action Plans

  • Investigations should lead to firm action plans. There can be a good process, but learning is then ignored, especially in dysfunctional Trusts.


  • Needs a process to ensure that learning is implemented. For example, quality committees.
  • Customer involvement in improvement and repairing ‘damage’ is essential.
  • There should be an audit of action plan implementation. Directors are accountable, and Regulators should check. 
  • CCGs should be responsible for checking action plan implementation but this rarely happens. 

Mysteriously, a Panel Member asked Dr Kirkup if his experience clouded his judgement of the NHS overall. Why does a Panel (whose own independence has been questioned) challenge a truly independent witness?

Bill Gates Adage

Dr Kirkup was asked how to treat families, who are not happy with the outcome of an investigation, and how to support them long-term.

He emphasised that the first time is the best chance of getting it right, adding that this often doesn’t happen and the longer it goes on the worse it gets.

Families are best experts on their own case.

Read more by leading expert Anita Toth¹→


Dr Kirkup sees a role for mediators – not in investigations but in mending fences. However, both parties should be willing to engage in the process with an open mind. He emphasised that they should be run by an independent professional mediator – not a clinician. At Morecambe Bay, he thought it was successful in certain cases after the investigation.

Dr Kirkup believes that the role of Medical Examiner is vital – but they only should be involved as a ‘long-stop’ and should not be an employee of the Trust. 

The best compliments heard about Dr Kirkup’s evidence are expressions of regret that he was not Chair of this Panel. However, if the Panel assesses Southern Health’s leadership and service users’ evidence against Dr Kirkup’s observations, its report will be damming.

50349497 - boy wearing a dunce hat

Clearly, the current leadership at Southern Health NHS Foundation Trust has shown no wish to engage with its most unhappy customers – the bereaved families.

It refuses to use them as any source of learning.

Indeed, it has done exactly the opposite!



Dr Kirkup was followed by Dr Josephine Ocloo (Senior Researcher and Health Foundation Improvement Science Fellow at King’s College, London) and Keith Conradi (Chief Investigator at Healthcare Safety Investigations Branch).

Their evidence is so important that it warrants a separate report. For now, we must credit Jospehine for her description of historical cases as, “The dark side of the NHS.”


¹ “When you have a lot of unhappy customers demanding limited time and limited resources, the financial cost can be big—from hundreds to hundreds of thousands of dollars. The faster you can reduce the number of unhappy customers you have, the better it is for your business.” [Anita Toth, ‘Bill Gates Says Unhappy Customers Are Good for Your Business. Here’s why’, first published 22 October 2020 in ‘Entrepreneur Europe‘.]

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“) 

Cloud Cuckoo Land?

Young man keeping mind conscious.Another weird week (ending 19 March) in the ‘not-so independent’ Public Investigation into Southern Health NHS Foundation Trust: a complete absence of service user/family/carer witnesses and no robust challenges by Panel Members.

Terms of Reference (“TORs”):

Before asking questions, ‘independent’ Panel Member, Dr Durkin asserted that the Panel’s role was to look at the current and future – not the past. This is an alarming departure from the TORs, which state that the Panel would consider:

“The extent to which the Trust has implemented recommendations from previous reviews and investigations and where further improvements can be made.” 

“The supervision structure that has been in place since 2011 by the Clinical
Commissioning Group [“WHCCG”] … and how it has been exercised towards the Trust in relation to complaints and investigations, and of any planned changes in the light of public concerns.”

The key previous inquiry was the Mazars Review [January 2016]. Dr Durkin, did you not notice that 2011 and 2016 are not the current or the future! Could your refusal to address the past relate to your role as NHS National Director of Patient Safety [2012- 2017]? Surely not!

There are countless adages on this subject too – from the 14th to the 21st century:

“The past resembles gthe future more than one drop of water resembles another.” Ibn Khaldun [1332-1406].

“In order to plan your future wisely, it is necessary that you understand and appreciate your past.” Jo Coudert [1923-2015].


Dr Katrina Webster, Clinical Lead, Mental Health & Learning Disability, W. Hampshire CCG.

Thumbs downEmployed by WHCCG since 2011 so ideal for the Panel to question about the supervision structure in place since 2011 as per the TORs. They failed to do so after Dr Durkin’s intervention.

She made several questionable claims: for example the Trust engaging more with families and service users; an improvement plan in place since 2016; and that the Trust had acheived its targets on care plan standards. No doubt unwittingly, she identified the difference between policies/plans and outcomes. She went on to say that 80% of carers didn’t know about care plans and others didn’t think they were worth the paper they are written on – yet the Trust is allegedly meeting its targets!

She had never seen some reports; could not answer key questions; and has no data to show discharge planning from secondary care had improved – she just ‘believed’ it. CRASH’s Freedom of Information Requests suggest that s.117 after-care¹ is a shambles. 

She admitted that Southern Health is not as good as other Trusts on communicating with patients, families and carers, “Until you find the right people, which is difficult.”

Steven Hales, Deputy Chair/Lay Member Working in Partnership Committee (“WIP“)

Thumbs down

Mr Pascoe started by emphasising that the Panel was especially interested in improvements in the last year, i.e. forget the TORs again!

Steven made some surprising assertions, which were at best exaggerated and at worst inconsistent with reality, for example about service user/family/carer involvement.

He engaged in his fair share of service user/family/carer blame, claiming that some complainants will never be satisfied and the priority should be how complainants are dealt with now. Again, forget the past! He claimed it was a communication problem to reach out to those who really hurt to convince them that things are different. He talked of advertising, public relations and leaflets. This is pure spin.

The answer is easy. TALK TO THOSE WHO HURT (the Trust has contact details) and remember, THE CUSTOMERS IS ALWAYS RIGHT. 

Most customers, who are now hurting, could have been satisfied if the post-2017 regime had not brought to an end co-operation with the Forum for Justice and Accountability at Southern Health (“the Forum”) and later with the breaved family group (set up by Alan Yates as Interim Chair). Initially, we were consulted and decribed as ‘critical friends’ of the Trust.

Indeed the Pascoe Investigation might have been avoided if, after Alan Yates left, the new regime had not brutally ended co-operation with the bereaved family group and ‘kicked the Forum into touch’. Could this be because the Chair and both CEOs are fearful of the members’ combined expertise and their robustness in challenging the Board. Surely not!

Notably, Stephen said one governor normally attends WIP meetings. ONLY ONE? 

He claimed Southern Health is not the same as it used to be and that it is safer now. He would not hesitate to refer his friends and families to the Trust. All talk and no evidence.

Amelia Abbott, Carers Strategy Project Officer/Triangle of Care Project Lead

Thumbs logo - greenJoining 9 months ago, Amelia made a refreshing change – a Southern Health official with genuine enthusiasm for her role; keen to make improvements; and with an impressive grasp of the Triangle of Care (“TOC”).

She was unafraid to expose the Trust’s continuing shortcomings. For example, the Forum have been recommending the TOC since 2016, and despite the Trust’s deadly failings in family liason exposed at two Inquests just 3 months apart, Amelia admitted that the Trust hasn’t achieved Stage 1 accreditation 5 years later. The Forum could make significant contributions to assist – if only we were allowed to do so. For example:

India realistic waving flag vector illustration. National countrAt a Board Meeting on 4 December 2018, CRASH suggsted the Trust should adopt two sections from the Indian Mental Health Act 2017 (“IMHA”) as best practice. Minuted here→

We contacted the two experts named by the Trust, Prof. Dimash Bhugra and Prof. Sir Simon Wessely. They agreed that section 98 of the IMHA could be used in UK as ‘best practice’ without changing UK law:

“S.98 (1): When a PMI² is discharged into the community or to a different mental health unit or a new psychiatrist takes over, the existing psychiatrist must consult the PMI, the nominated representative and the relevant family member or carer. (2): The existing psychiatrist will, in consultation with the persons referred to in s.98(1), ensure a plan is developed as to how treatment of services are to be provided.” 

We also found useful guidance in the World Health Organisation Rule Book.

Simples! TOC and Care Planning improved in one go – if the policy is strictly applied. Yet has this been implemented? We doubt it – we continue to see failings in care when inpatients are discharged or transferred between hospitals and/or Consultants.

Amelia made useful observations on TOC training. At first, she saw an average of only 6 staff on courses but this is increasing: her next course is full. Even more enlightening (if unsurprising) is that she typically saw nurses and allied health professionals – but only occasionally Consultants and doctors. She agreed that better data is needed on this.

Beth Ford, Service User Involvement Facilitator

Thumbs down

Beth is to be commended for disclosing her autism and mental ill-health but, having asserted that the Panel (as a result of her autism) would only hear the truth, she made two seriously misleading statements, perhaps unwittingly.

  • She claimed there were no Out-of-Area Placements. If this were true, why would Southern Health invest £3.3m on two new mental health wards with a total bed capacity of 28. The target opening date is Summer 2021. One ward is specifically to “Provide  mental health support to women  in a bid to prevent the need for treatment outside Hampshire.” Marchood Priory is still receiving NHS-funded patients too. 
  • She denied that the Trust is responsible for 111 services – a half-truth: Dr Broughton set up a specialist 111 team manned by Southern Health staff but based at the 111 call centre. We know this after supporting a service user in a complaint about 111.

  She made a number of other dubious assertions. For example:

  • To talk with as many service users, carers, families as possible to gather feedback. 
  • Before 2019 (when she joined) she would not be treated by the Trust. Now she would. To misquote Mandy Rice-Davies, “Well, she would say that, wouldn’t she?”
  • There has been a major culture shift at Southern Health since she joined.

However, most alarming revelation was the description of her day-to-day activities. She alleged to have: all-points access to Trust units; unsupervised access to patients and their records; free reign to upbraid Southern Health’s clinical staff and others; and authority to resolve complaints on the spot. She also claims to barge into Directors’ offices on a whim and admits to occasional use of inappropriate language in doing so. 

super cop from the future, cyberpunk. Police

Beth – ‘Robo Cop‘ of Southern Health?

However, the NHS includes as common signs of autism – finding it hard to understand what others are thinking or feeling and seeming blunt, rude or not interested in others without meaning to.

Indeed, we believe there are serious risks in an autistic person carrying out this role unsupervised – including a risk to the person doing so. Indeed, is this not a role for Board and Divisional Directors?    

Two observers could not believe their ears – despite their combined business experience, including Quality Improvement, they had never seen such a bizarre management structure. 

Scary EmogiEven allowing for her disability, if Southern Health’s Board truly believes this attitude and modus operandi will encourage service users, families, carers and staff to speak up truthfully, they are sadly mistaken – living in Cloud Cuckoo Land one might say

Again, all Beth’s evidence related to the alleged improvements since 2019. She did say, without a hint of irony, that she felt some NHS staff were intimidating people! She made other interesting points, which require further research, relating for example to complaints handling, use of generic email addresses and unpaid service user volunteers.


Two ex-Public Governors summed up Southern Health’s management structure succinctly.

“All the plans are bolt-ons – find a problem and form another committee with little oversight. You can’t buy a Land Rover and turn it into a F1 racng car by buying and bolting on extras.”🙁

“I’m getting the hang of their modus operandi. Let one CEO move on, and blame him for everything if convenient! (They didn’t seem as bold to blame that woman [Katrina Pecy] when she led the Trust!) I’m quite perturbed at Lynne, because [redacted for legal reasons]. I believe a lot is being done to undo the good work of public involvement and holding to account during these Covid times. I would not be surprised that there will be lots of scandals afterwards.” 🙁

In short, transformation of Southern Health is a long, long and very dusty ol’ road.   

Badwater road Death Valley National Park CaliforniaWith apologies to Jerry Jeff Walker


¹ Section 117 of The Mental Health Act 1983 (as amended) makes Local Authority Social Services and CCGs entirely responsible for aftercare.

² PMI – patient with mental illness.

³ Cloud Cuckoo Land: a state of absurdly over-optimistic fantasy. As in, “Anyone who believes that these plans will be effective is living in cloud cuckoo land”.

(opens in 

Little People

Sketch of working little people with scale

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. 

Question Mark 2Firstly, there were positive undertakings from Mr Nigel Pascoe QC, Chair of the Hearing and Paula Hull, the Trust’s Director of Nursing & Allied Health Professionals.

Now we have to see if they will be honoured.


Witness Intimidation: 

Mr Pascoe issued a warning over attempts to intimidate witnesses giving evidence:

Watching in Aggression - Retro Cartoon Office old Boss Man Vecto

“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.

Dissatisfied Complainants:

Paula Hull issued what amounted to an open invitation to all dissatisfied complaints to contact her to discuss their outstanding concerns.

Laughing with tears and pointing emoticon

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.  

Thumbs down

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

Thumbs logo - green

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.

Do as I say

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:

  1. Not hold the Trust’s Board to account after the then-Chief Executive Officer brutally ended co-operation with the families in December 2018?
  2. Not ensure the current CEO re-engaged with them?
  3. 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.

In Memoriam.

Jo Deering 1 

Jo Deering, a much-loved lady lost too early, and whose family still await justice after almost 10 years.    


© Dr Maureen Rickman




¹ Crown Prosecution Service, Charging Standards for Public Justice Offences.

² Ditto – Misconduct in Public Office

³ Do as I Say (Not as I Do): Profiles in Liberal Hypocrisyby Peter Schweizer  


Sideshow: 1. A minor show or exhibition in connection with a principal one, as at a circus.  2. Any subordinate event of matter.¹

So the Public Hearing into Southern Health NHS Foundation Trust, which resulted from the deaths of five vulnerable people, opened with an odious statement by Mr Nigel Pascoe QC relegating the bereaved families to a sideshow – a subordinate event. A fully copy of his statement (for publication) is here→

Amongst other objectionable parts of his statement is:

“As Chair of this investigation, I have decided today not to make any comments on either of the responses given by the families. To do so would be to prolong their agony, with the added danger of creating a sideshow.”

And yet, relegating the families to a sideshow and not explaining their failure to reengage, did exactly what he claimed he wanted to avoid. Family members who watched his statement were so upset that they are unlikely to log in to the hearing any more.

One of Mr Pascoe’s more objectionable comments concerned the Panel Members:

“I have no doubt whatsoever that they cherish their independence.”

Changing the gender in Hamlet by William Shakespeare: 

The man doth protest too much, methinks”²

It insults the intelligence of the families, the media and the public. A TV reporter has already identified it. It is a key reason why the families withdrew – no wonder Mr Pascoe refused to expand on the subject – and didn’t even allow the Panel Members to introduce themselves so the public could judge for themselves. The families’ full statement is available here and we quoted subsequent statements here. The families asserted specifically:

“The idea of spending a few more months locked into an exploitative relationship devoid of trust, with people who mock the word independence [our emphasis].”

For good measure, Mr Pascoe engages in the NHS-practice of media/family blame:

“Nothing will deflect us from pursuing that objective, no matter how much noise there is in the public arena.”

The, “Noise” Mr Pascoe was (amongst other things) caused by NHSE’s failure to produce Terms of Reference (“TORs”) that met the families’ expectations and a panel, which no reasonable person would perceive as indepenedent. And you, Mr Pascoe agreed them.

No wonder Mr Pascoe did not want to address the families withdrawal in detail. Clearly, it had more to do with concealing the fatal flaws in the TORs and procedures. His statement served only to prolong their agony.

Here are some comments about Mr Pascoe’s opening statement by bereaved family members [unredacted, save for identities, with emphasis added}:

Family member 1.

“Thank you for sending this slimy statement – it is interesting insofar that Pascoe clearly feels compelled to explain and justify his decisions !!!!! And he does so (notably in the same manner as the [unsigned] panel statement) without explaining what is meant by ‘CONSTRUCTIVE CHANGE’!!  His claim that he was left with just ‘two choices’ is plain bullshit as if he  had he actually carried out an investigation into the ‘quality of investigations’ he would have found more urgent issues to consider than Trust policy!!!!!!!!!

Family Member 2.

“Thank you [CRASH] for your work and support, without you we’d have none whatsoever. 

“You’re right, his opening statement made me feel totally vindicated for removing ourselves from this deeply biased, heinous process.  I would not want him or the ‘not so independent’ Panel to sully the memory of our deeply loved, beautiful [redacted].” 

Family Member 3. 

“Thank you for taking the time to send this on to us. I will be interested to see the outcome and whether anyone will actually ask why we didn’t go ahead?

Don’t hold your breath!

TV Journalist.

CRASH spoke to a TV reporter on the second day of the Hearing. It was an interesting conversation. She agreed the lack of independence of the Panel, commented on the small number of service user/carer witnesses, and the unconvincing  procedure. 

The Daily Echo reports (here) that one bereaved family member is so distressed by this charade that she has written to the Prime Minister and Secretary of State asking for a genuinely independent investigation. 

Witnesses:  Thumbs down

In talking of witness numners, the TV reporter was spot on. Also Trust witnesses did not inspire confidence that they had a grasp of their brief.


We should however express sympathy for Julia Lake. She became Deputy Director of Nursing when the formidable³, Florence Nightingdale Scholar, Sara Courtney left about four months ago. It reflects poorly on Southern Health’s leadership that they cannot retain the services of a well-respected officer and put up a new appointee for such an onerous and stressful task.   

It was notable also that witnesses were asked to attest that they would tell the truth but there was no means of checking if they were doing so. We will go no further now than saying that several questionable statements were made to the Panel.

Laughing with tears and pointing emoticon

Others were simply laughable.

None were challenged.



Thumbs logo - greenService User Witness

Credit must go to service user, Mr Matt White who made five extremely  good suggestions.


As there is no recording or transcript available to the public, I hope I have noted them accurately. They are excellent ideas. Matt started by asking how to complain about the complaints department – that speaks for itself! He had reached five conclusions!  

  1. Moving forwards, staff should follow their employers’ policies, first and foremost. [Otherwise] it’s a pointless document. [Applies to Directors as well as staff. Ed.]
  2. Professional negligence insurance should be available for complaints handlers/investigators [Not clear on this one. Ed.] 
  3. Clinicians should record their thought processes in patients’ medical records as well as facts and decisions.
  4. Evidence suggests that the complaints department should itself be independently investigated.
  5. Selection & Training of investigators needs to be more robust with accountability. Second investigator not up to the job: when challenged went silent.

Matt, who has questions unanswered since 2017, said that the complaints process was very hard work; damaging to him; not made easy; still has unanswered questions. He had seen no improvements since 2017. He still feels no closure or resolution and feels he has exhausted all options. He referred to deep psychological and emotional harm.

Matt hit the ‘nail on the head’ – staff (including leaders) don’t follow policies and the complaints department itself needs independent investigation including of its supervision – hopefully more independent than this charade. The families reasons for withdrawing included the TORs only allowing the Panel to consider the robustness of policies – no point in that because the Trust (including leaders) often pay scant (or no) regard to its complaints policies and procedures anyway.  

And finally:

For those who wish to form their own opinion, next week’s schedule for the Hearing (including witness details) is here 9 – 11 March witness schedule for publication. 

Links to the hearing (on Microsoft Teams©) are available from the Panel Secretary, Alice Scott – 


¹ Sideshow | Definition of Sideshow at

² A cynical, ironic, somewhat sarcastic comment about someone overdoing a denial, suggesting that they are, indeed, to some degree guilty.

³ We interpret ‘Formidable selectively as, “Inspiring respect through being impressively capable” as in, “A formidable upholder of service users’ rights.” We do not mean, “Inspiring fear through being impressively large!!!”   

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

Lockdown Well-Being

YogaImage via Unsplash

Guest Post By: Stephanie Haywood – My Life Boost

How to Stay Healthy During the COVID-19

While you’re doing your part to stay inside and limit social contact during the COVID-19 pandemic, it doesn’t take long for cabin fever to start setting in. Starting a home workout regimen is one of the best ways to give your day structure and stay fit and healthy. You can also meet your health goals by cooking delicious meals at home and making time for self-care. Read on to learn about some helpful resources.

Appealing young lady in light blue outfit sitting in tragic postureMaking and Using a Home Workout Space

Even though you’re at home, there are still tons of workout possibilities. Whatever your choice of workouts, make sure to build out your home gym according to your needs.

Further useful guidance at:



  1. The Best Home Gym Accessories
  2. 6 Warmup Exercises to Help Boost Your Workout
  3. The High-Intensity Cardio Workout You Can Do in Your Living Room
  4. Planning Your At-Home Dumbbell Weight Training Program
  5. 8 Cool Down Exercises That Can Make Your Workout More Effective

Practicing Self-Care at Home

Along with establishing a fitness routine, self-care is essential during the pandemic. Look to eat nutritious meals and find new ways to relax. Further useful guidance at:

  1. A Short Self-Care Yoga Practice for Busy Days
  2. 3 Reasons Why Cooking Can Be a Form of Self-Care
  3. 7 No-Fuss, Self-Care Foods You Can Make to Cozy Up
  4. The Best Meal Delivery Services
  5. House Cleansing: A Checklist for Clearing Bad Energy from Your Home
  6. 15 DIY Self-Care Ideas Using Essential Oils
  7. How to Make Your Bubble Bath the Most Relaxing
  8. 7 Foods That Help Fight Depression and Anxiety

Yoga Silhouette Background

Even when your yoga studio or gym is closed and you can’t do your normal routines out in the community, you can still prioritize your health and wellness at home. By setting yourself up for home fitness and carving out time for self-care, you can make it through COVID-19 in better spirits and stay healthy.


Stephanie Haywood – My Life Boost


EDITOR’S NOTE: How to safely return to exercise after COVID-19

Problems can appear when people push too hard on a body that’s trying to recover from illness: it warrants extra caution so that patients don’t hurt themselves as they’re eager to resume a healthy, active lifestyle. If in doubt please seek medical advice.

Doctors have warned that, even after a mild case of coronavirus, many COVID-19 survivors trying to get back to their exercise routine will discover a body that’s changed long after their initial symptoms have come and gone. Read more here→