Spinning around, spinning around

KONICA MINOLTA DIGITAL CAMERAWe thought we had written enough about poo but found some for sale very close to Southern Health’s HQ shortly after seeing their take on the latest CQC report. It appears to us that Southern Health have been busy polishing again.

CQC report (lower half of page 1):

CQC Report ReducedNo ‘Outstanding overall ratings: read the full CQC report here→

Southern Health’s News Release, paragraph 1:

“Today (2 October 2018) the Care Quality Commission (CQC) have published their comprehensive report into Southern Health NHS Foundation Trust. Whilst the Trust remains rated as ‘requires improvement’ overall, the CQC have found many signs of progress across the organisation, with over 84% of service areas now rated as ‘good or ‘outstanding’.”

Whirligig icon cartoon

 

(Spinning around, spinning around)
(Oh)
I’m spinning around.¹  

 

Read the spin news release here→. Sadly no mention  here of the leadership requiring improvement.

Readers can compare the two and draw their own conclusions. 

CRASH is sure there are caring and responsive staff at Southern Health, who warrant a ‘Good’ rating but what is the point of caring and responsive staff when patient safety, effectiveness of services and leadership all require improvement?

Indeed, we can reasonably argue that Southern Health would recruit even more permanent caring and responsive staff (saving money on locums, freelancers and ‘bank staff’), if prospective recruits believed they were joining a safe, effective, well-led Trust.  

2013 MTV Movie Awards

 

(Sorry boys – Royalty Free images, very limited)

¹ Kylie Minogue

Lyrics here

 

 

 

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The ‘Do nothing’ Advice

Quote

“Do nothing … if you can, take the rest of the day off.”

5892231 - crying crocodile

 

via Crocodile tears and the ‘do nothing’ advice

 

 

 

As usual, inciteful and poignant observations by Dr Sara Ryan, this time on attitudes to complaints and complainants within the NHS. It follows an article by Clare Gerada, Lady Wessely, an ex-chair of the Royal College of GPs and member of the Council of the British Medical Association. She is a Fellow of the Royal College of Psychiatrists too.

On receipt of a complaint, Gerada advises doctors to:

“Do nothing … if you can, take the rest of the day off.”

That’s not a luxury available to bereaved families or those suffering harm as a result of clinical negligence.

Extracts from Gerada’s twitter account (#FBPE @ClareGerada) also posted at Crocodile tears and the ‘do nothing’ advice include the following gems:

“It’s easy to complain. No risk to complainant. Sadly they kill doctors.¹”

And after a reply pointing out that it’s not always easy to complain, Gerada responds:

“It should be difficult. And patients should think very carefully. Complaints kill.¹”

So now folks, we (complainants) kill doctors!

And yes, there is a risk to complainants, who often suffer symptoms of stress in ‘taking on’ the (already far too ‘difficult’) NHS complaints system. We know one complainant, who suffered PTSD as a result of complaining about clinicians, and others whose mental health has been harmed.  One would expect a reasonably skilled Fellow of the Royal College of Psychiatrists to appreciate the risk of psychological harm to complainants.

What are the chances of transforming the NHS if Gerada’s ‘old-school’, defensive attitude prevails? Contrast this with the patient-centered culture of Virginia Mason Medical Centre, the world’s leading authority on Total Quality Management in healthcare:

“Stories have a profound impact on medicine – patient perspectives have the power to inspire an organization and strengthen the commitment to improving the quality, safety and delivery of health care.

“Capturing the patient voice opens the floodgates to know when the patient is feeling more vulnerable, lonely, worried, empowered or happy along each point of their care journey. Their experience can help inform where improvements can be made along the way.

“Through empowerment and solicitation of patient input, the patient experience can be fine-tuned, even perfected.”

Perhaps Gerada could attend ‘Eliminating Preventable Patient Harm‘ – a two-day course at The Virginia Mason Institute™ (please, not at taxpayers’ expense) or watch the webinar: Capturing Value in Patient Voices and Perspectives‘.

Very sad for a leading GP not to understand that, if the NHS is to become a safer place, complaints should be encouraged, investigated diligently and lessons learnt. Gerada’s attitude reminds us of the, “Patronising disposition of unaccountable power!” 

We are all for taking a break from the stresses of working life but the recipient of a complaint should (and must) ‘Stop the Line‘; report the incident; and ensure it is investigated immediately, especially if it represents a serious risk of harm if repeated.

Indeed, an inciteful clinician, who makes a mistake, should not be surprised by a complaint – he/she should have self-disclosed it already and have an answer before the complaint is received.

The goal should always be to achieve a zero defect healthcare system, in which customers always come first. 

And after the problem is solved and the risk eliminated, then take the whole of the next day off, relax and do something different (preferably with exercise), confident in the knowledge that the incident will not recur.

For example: take an alpaca for a walk²!
KONICA MINOLTA DIGITAL CAMERA

¹  We do not trivialise situations in which anyone has died, including clinicians: all deaths (or harm), suspected of being preventable, should be investigated with the same speed and vigour, regardless of the patient’s profession.

²  Petlake Alpacas of the New Forest  [Image © CRASH]  

Alpaca Walking Experience RECOMMENDED   Gold Star Minute   Gold Star Minute   Gold Star Minute  Gold Star Minute  Gold Star Minute    or Gifts

Reminder to self: if relocating to London do not register at a Hurley Group Medical Centre – of which there are many – your GP might have taken “The rest of the day off.”

Money, Money, Money

“If I got me an NHS fat cat, I wouldn’t have to work at all I’d fool around and have a ball,

40261762 - cat with the computer mouse.

“It’s a rich man’s world”¹

In a comment on ‘mydaftlife‘, we questioned the need for more money in the NHS – at least before layers of non-clinical managers are stripped out; bureaucracy reduced dramatically; fat-cat salaries of non-clinicians brought under control. We should add clinicians acting as bureaucrats and improved debt-recovery from health tourists.

BUREAUCRATS:

Last year ‘The Daily Telegraph‘ alleged amongst other things that:

  • Over 600 NHS quango chiefs earned in excess of six-figure salaries.
  • Doubling in the number earning more than the Prime Minister in three years.
  • The nine main health quangos employed 628 officials on salaries of over £100,000.
  • NHS Improvement alone had 79 officials on six-figure salaries.

Many of these high earners make frequent repeated demands on Government [i.e. us, the taxpayers] to increase NHS funding. Read more→

And it doesn’t end at national level. On 27 July 2018, ‘The Daily Telegraph‘ reported that Clinical Commissioning Groups in Sussex propose rationing hip replacements. Patients are expected to endure “uncontrolled, intense, persistent” pain for six months before referral for operations. Coastal West Sussex CCG employed an Interim Chief Finance officer at an annualised salary of £330,000 a year. This could have funded around 60 hip replacement operations². Read more→

Comparison: The Prime Minister is paid £150,402 a year, including the basic salary for an MP, which is currently £74,962. It doesn’t factor in the value of the Prime Minister’s flat in Downing Street, or other official residences – but then, who wants to have two jobs and live ‘on the job’ too? [Source: Full Factthe UK’s independent factchecking charity.]

Perhaps the salary of Simon Stevens, CEO of NHS England should be capped at the same level as the PM and other senior NHS officials at the level of equivalent Secretaries of State, Ministers and so on down the slippery pole. NHS England’s 2017/18 Annual Report shows that Simon Stevens earnt £190-£195K plus £45-£47.5K pension.

Solution: To his credit, it is reported that, in 2017/18, Simon Stevens voluntarily took a £20,000 per annum pay cut for the fourth year in a row, i.e. circa. 10%.

So, even if the 600 NHS quango chiefs and 628 officials are only earning £100,000 each, a 10% salary cut over for the next four years, would save the NHS £49.12 million.  

This would fund dialysis for up to circa 396 patients with renal failure every year.³

HEALTH TOURISTS 

41498855 - medical tourism vector background

 

There are two types of Health Tourist:

1. ‘Deliberate’ users of the NHS.

2. ‘Normal’ users of the NHS— foreign visitors who’ve ended up being treated while in England.

© Sayan Bunard

 

We concentrate here on ‘Deliberate users’ – those who come specifically to receive free treatment or who come for other reasons but take advantage of the NHS when here.

In July 2014, the Department of Health published its: ‘Visitor and Migrants NHS Cost Recovery Programme‘. Despite this, the ‘Mail on Sunday‘, reported recently that, NHS Improvement estimates hospitals should be collecting £167 million/year from overseas visitors, but are only recovering £113 million, a £54 million shortfall. Read more→

Labour wards are especially affected: two years ago, St George’s Hospital in London admitted that a fifth of its deliveries – up to 900 births – were to women who flew in from outside Europe. That’s a cost to the taxpayer of £6 million – at one hospital..

Solution:

Recently, NHS Un-Improvement (as it’s sometimes known) launched a crackdown on health tourism sending ‘hit squads’ into 50 NHS Trusts – no doubt at great expense.

Is there an alternative?

UK-aid-logo reduced

 

UK Aid from the British People, doled out by the Department of International Development (“DFID”), is detailed in ‘Statistics on International Development: Provisional UK Aid Spend 2017

 

Total provisional expenditure for 2017 by “The British People” was £13.933 billion, including £3.828 billion from other Government Departments and organisations.

Notably, one of the other government departments was Health & Social Care: it contributed £101 million of our money – an increase in £55 million over 2016

So, rather that hiring ‘hit squads’, why does the Secretary of State not just set up a system whereby NHS Trusts simply bill DFID, which pays the Trust and deducts it from its overall budget. Is that too simple for the Sir Humphreys in Whitehall?

After all, one of the objectives of Overseas Aid is to promote economic development and welfare of developing countries as its main objective. What better way of promoting welfare than to pay for the healthcare of their citizens, who come here.

RELATED STUFF:  

Talking of fat cats, in our main source of images this week, we found this – genuine original – no photo-shopping:

48116033 - percy word on banner and bikiny womanThis one said farewell taking circa £250K (including pension and benefits) for being “Bad at her job.” As ‘Scotlander’ commented in ‘The Oxford Mail’ on Katrina Percy:

“She could be a poster girl for NHS incompetence, waste and indifference to public opinion.”

© icetray

 

COMING SOON:

Comments on West Hampshire CCG’s Annual Report & Accounts: download here→

Red Mist

Footnotes 

¹ Adapted from ABBA “Money Money Money“: writer(s): Bjoern Ulvaeus, Benny Anderson, Stefano D’Orazio

² Based on £5,431 – £5,625 for “Very Major Knee Procedures for Non-Trauma” – Best Practice Tariff, NHS Improvement and NHS England: prices in 2017/18.

³ The National Kidney Federation – average cost of dialysis £30,800/patient in 2010.

Mental Health Man of the Week

KONICA MINOLTA DIGITAL CAMERAToday’s post was to be titled ‘Red Mist owing to recent interactions with Southern Health and others in the last two weeks.

© CRASH

At the last minute, we came across a much needed ‘good news’ story. (‘Red mist‘ follows.)

It is the heartwarming story of Chris Ryder (@CWRyder), lifelong supporter of Barnsley Football Club, who tweeted about his “anxiety, stress and depression” on 8 August. He then shared an image of a letter he received from the Club’s Chief Executive, Gauthier Ganaye (@GGanaye), who opened with an apology for writing at random and wrote:

“I felt like I wanted to reach out to you and get in touch.

“I’ve noticed through social media that you’ve had a bit of a hard time recently, I’m not sure what it is but I hope everything improves for you as soon as possible.

“You’ve been a fan of the club for many years and always supported us, so we want you to know that if the favour needs returning and we need to support you, please do let us know.”

Dkjc-BpWsAAlcsVGauthier continued:

“You are welcome to swing by any time. My office door is always open….”

Having urged Chris to contact MIND,  if he needs to, Gauthier closed:

“Keep supporting the Reds, Chris. We’ll keep supporting you.”

When the letter went viral, a spokesperson for the club told HuffPost UK:

“We feel that every comment we could make is in the letter, other than that obviously the door is open to anybody in the community [bold added] that needs us.”

Has anyone received such a kind, empathetic and sympathetic open invitation from a Southern Health Director – or a Director of any NHS organisation – much less an “open door” to anybody in the community who needs their organisation? 

Gaultier was the youngest Chief Executive in the football league when he was appointed to the role at Barnsley FC in May 2017, at the age of 29. Before that, he was on the executive committee for French team Racing Club de Lens.

MONSIEUR GANAYE: Southern Health is currently recruiting Non-Executive Directors. Its service users and bereaved families need your empathy and understanding – even more so to ‘balance’ its Board with Directors with experience of the ‘real [commercial] world.’

Other like-minded, experienced persons should also apply!

Information here→            To learn more email Company Secretary here→.

Come on you Reds“: … and for balance … “You ain’t seen nothing like the Mighty Quins.”

 

 

 

 

“Patronising disposition of unaccountable power!”

50132944_s reduced twice

In commenting on his Panel’s report on deaths at Gosport War Memorial Hospital, The Right Reverend James Jones KBE likened it to the title of his Report on Hillsborough, which  concerned the death of 96 Liverpool football fans at the 1989 FA Cup Semifinal:

“THE PATRONISING DISPOSITION OF UNACCOUNTABLE POWER”

Departmental sign at Gosport War Memorial Hospital, Gosport, Hampshire UK. Image shot 2009. Exact date unknown.His Panel concluded that the lives of over 450 people at Gosport War Memorial Hospital were shortened owing to an, “Institutionalised regime” of prescribing and administering opioids without medical justification.

 

 

Gosport War Memorial Hospital in now managed – you guessed it – by Southern Health, which issued a public statement containing the usual duck-billed platitudes¹. Read its statement here→ and the Panel’s Report here→

So we have:

So, from babies undergoing heart surgery (Bristol) to adults with physical ill-health (Mid Staffs and Gosport) to dying patients (Liverpool and elsewhere) to maternity and neonatal services (Morecombe Bay) to those with mental health issues and learning disabilities (Southern Health), it appears that all are at risk of similar patterns of behaviour by NHS clinicians and executives, as described in these Inquiries.

In his report on the high mortality rate of babies undergoing heart surgery at Bristol Royal Infirmary, Sir Ian Kennedy QC referred to:

“‘An old boy’s culture’ among doctors, a lax approach to safety, secrecy about doctors’ performance and a lack of monitoring by management [and] an arrogance born of indifference [our emphasis].”

And in the Liverpool Care Pathway review, Baroness Neuberger (and others) wrote:

“It is clear to us [from verbal and written evidence] that there have been repeated instances of patients dying on the LCP being treated with less than the respect that they deserve. It seems likely that similar poor practice may have taken place in the case of patients with no close relatives, carers or advocates to complain, or where families have not felt able or qualified to question what has taken place. This leads us to suspect this is a familiar pattern, particularly, but not exclusively, in acute hospitals.

“Reports of poor treatment in acute hospitals at night and weekends – uncaring, rushed, and ignorant – abound [our emphasis].”

Patronising, unaccountable power, institutional regime, ‘old boy’s culture’, lax safety, secrecy, lack of monitoring, arrogance, indifference, disrespect, poor practice, uncaring, rushed and ignorant? Surely not!

Headless Chicken - reduced

 

And when ‘found out’, NHS executives run around like headless chickens to cover their backs rather than adopt recognised Crisis Management techniques and learn.

 

 

business-people-silhouette-clipart-panda-free-clipart-images-DZ4NzG-clipart reducedAnd, as soon as the crisis appears to have been resolved, let’s return to square one.

¹ More on duck billed platitudes here→

Polishing a turd

Turd V2

CRASH prefers to avoid the vernacular but, if, “Polishing a turd“¹ is OK for UK Cabinet Meetings, it’s OK here. Also, we found it had already been used about Southern Health [Sloven] – on December 5, 2015 at 7:16 pm – by ‘thelovelywibblywobblyoldladyon Dr Ryan’s blog (here) in the run up to publication of the Mazars Review:

“It must by now be plain and obvious to all (including Sloven) that the report is so damning, Sloven are attempting to polish a turd before the report is (finally) released.”

Unfortunately, after a brief clean up by second Interim Chairman, the excellent Alan Yates, it’s time to get the shovels out again. Southern Health has revived its slippery complaints handling (and other) tactics. For example:

  • Disclosing data without third party consent, when it suits the Trust to do so and especially when the data is grossly inaccurate.
  • Withholding third party data, on which consent has been granted, when it suits the Trust to do so.
  • Refusing to disclose data relevant to a complaint.
  • Appointing a senior official to liaise with a complainant and supply evidence, rather than the Complaints Manager and her staff.
  • Deny complainants equal access to evidence, especially transcripts of interviews with those accused of misconduct.
  • When this skulduggery is identified, instruct the investigator to publish a draft report and set an unreasonably short deadline for the complainant to comment.
  • Recommend an advocacy organisation, which is, “Rationing” services and, “Driving towards getting people ‘self-helping'”, owing to lack of funding – ideal [for the Trust]in dealing with complaints from mental health and/or learning disability patients!
  • Offer help and advice from Advocates who are not permitted to advise.
  • Appoint an official, who is explicitly engaged in an incident, to handle the resulting complaint and check the draft investigation report for factual accuracy!
  • Attempt to trick complainants by quoting GDPR³ and The Data Protection Act 2018 as a defence to data breaches when the breach occurred under The Data Protection Act 1998, i.e. before the new legislation came into force³.  

Probably more bullet points to follow!

Southern Health has not responded to a request for comment.

And the Chief Executive of an Advocacy Service commented recently, in writing:

“It is clear from my conversations with [advocate] that [Southern Health]  managers have put their own spin on the recorded communications that date back to 2016 and these have been embellished to their advantage, which is highly unprofessional.”

36657660 - cartoon of businesswoman, the dilemma of a whistle blower.

 

And what of Southern Health’s whistle-blowing policy, in which CRASH was consulted at the instigation of Alan Yates.

 

 

We believe Southern Health’s Freedom to Speak-up Guardian is a decent and professional individual but cannot be expected to be available 24/7. So the Trust decides Complaints Team members should act as back-up contact for whistle-blowers, despite that they report to an Associate Director, who does not believe complaints staff should take whistle-blowing disclosures and has already identified one whistle-blower.

94237238 - girl collecting horse excrement in shovel at stableyard

 

It’s time to get the shovel out again Alan.

Next [and related] post: “Patronising disposition of unaccountable power!”²

 

 

 

Turd Polish

 

¹ Trying to make something hopelessly weak and unattractive appear strong and appealing. An impossible process that usually results in a larger, uglier turd [Urban Dictionary]. Buy your own sewage polishing filter pads from Amazon here→!

And proof it can be done→

²  Title of Hillsborough Report by Bishop James Jones.

³  General Data Protection Regulations (“GDPR”). The Data Protection Act 2018 received Royal Assent on 23 May 2018 in advance of the application of GDPR on 25 May 2018.

LeDeR and Leaders

The LeDeR Report was published on Friday, 4 May: three years of Bristol University’s project reviewing the premature deaths of learning disabled people. Coincidentally, on 9 May, Southern Health presented itsFuture plans to develop our Secure Forensic Mental Health and Learning Disabilities Services.

The LeDeR Report

There is plenty of blog commentary on the LeDeR Report by Dr Sara Ryan, Mark Neary, Mark Brown, two posts from Professor Chris Hatton here and here. Also an opinion piece by Ian Birrell here. All worth reading.

Key issues (Dr Sara Ryan)
1. The findings of the report (shameful).
2. The underfunding of the work (shameful).
3. The attempts to bury the report (shameful).

Those referred to above have far more knowledge of learning disabilities than CRASH. Our education has come from Sara and the preventable death of her beloved son Connor; Jane and Ian Hartley, whose son Edward had profound learning disabilities and died aged 18 in May 2014 following complications from an epileptic seizure; and others who lost loved ones whilst in the ‘care’ of Southern Health.  Our eyes have been opened, not only to the care (or lack of it) of persons with LD by the State but also of the valuable contribution they can make to society.

Future plans to develop our Secure Forensic Mental Health and Learning Disabilities Services [Southern Health]

On Wednesday, 9 May at a public meeting, Southern Health presented its future plans for secure forensic adolescent mental health services and for adults with Learning Difficulties. A summary of the strategy is available here→; a full colour presentation here→;  and plans for the Proposed New Learning Disabilities Residential Unit on the Rufus Lodge site here→.

Credit, where credit is due – the need for more beds for forensic psychiatric adolescents and improved LD facilities is ‘a given’. The architectural plans are very impressive but perhaps the most poignant comment came from a Governor:

“I am sceptical of new buildings for projects, its the mindset of the people that matters most.”

The adolescent forensic services should be OK under Dr Mayura Desphande – an excellent and empathetic Consultant – if she can get the staff. Our concerns are:

  • However impressive the architectural plans,  in the end it’s the expertise and empathy of management and staff that matters.
  • Southern Health already has  staff recruitment problems for hospitals on the Tatchbury site, owing to its remoteness and recent history: when the building work is finished, they will need more specialist staff.
  • The temporary but lengthy transfer of adults with learning disabilities from a reasonably pleasant environment at Woodhaven to Ravenswood – only one step down Special Psychiatric Hospitals, such as Broadmoor. Unless he has been moved since 2015, Ravenswood houses infamous hack-saw murderer Daniel Rosenthal¹.
  • Ravenswood also is an old building.
  • The plans also rely on strengthening the Community Mental Health Teams.

The Trust says that patients, family and carers and staff have all been informed but were they told the true nature of Ravenswood or given the opportunity to see it? 

One disappointment – we asked the lead officer for the project if he had approached Dr Sara Ryan for her comments on the LD strategy and facilities. He answered : “I know of her.” We suspected what he meant – “No, I haven’t approached her“: we were right.

With the exception of the failure to approach Sara, at least this is a sign of the good intentions of the new regime, but, as they say, ‘the proof of the pudding….’²

If anyone has comments about this strategy can be left here or you can email the Trust’s Chairman, Lynne Hunt, or the CEO, Dr Nick Broughton.

Blue Star Minute

Bluestar here’s a heartwarming story about Bluestar bus driver, Mike Rogers, who helped an autistic boy get home after he boarded the wrong bus.  He has other learning difficulties, including attention deficit hyperactivity disorder.

Gold Star MinuteAnd a Gold Star for Mike

 

¹ Daniel Rosenthal   WARNING: The text and links below contain graphic descriptions

If your scribe was the family or carer of an LD adult patient, I would want to know if Rosenthal still resides at Ravenswood but (quite correctly) Southern Health won’t say on confidentiality grounds. Instead, I would certainly want serious reassurances about security (between wards) and expect a site visit.

Rosenthal’s history is detailed here –  in 2008, he had already spent 28 years in Ashworth Special Psychiatric Hospital for murdering his mother and cutting her up with a hacksaw. His Consultant Psychiatrist told Hampshire Police he would be recommending that Rosenthal never be released because he had made absolutely no progress.

Between 2008 and 2013, Rosenthal somehow managed to get transferred to Southern Health’s medium secure unit, Southfields. He hit the news again in August 2013 by absconding. Despite not improving in 28 years in Ashworth,  Southern Health claimed he had made “significant progress and recovery“.

True to form under its old regime, Southern Health misled the press and local residents (of which CRASH is one).

  • They claimed that Rosenthal posed an “extremely low risk” to the public, whilst he was simultaneously described as “potentially dangerous” by police, who issued urgent ‘dangerous, do not approach warnings‘ though the media.
  • They claimed initially that he had ‘gone over the wall‘ on an unsupervised walk in the grounds – only to admit, a few days later, that he had been granted formal leave – from which unsurprisingly he did not return.

Read more here→

Fortunately, the police found him fairly quickly – boozing in Southampton. I suspect this is when he was transferred to Ravenswood. He next made news in 2015 when he was given technical bail, whilst awaiting trial for the murder of his father in France 34 years ago. He had fled from France (before the French police found the body) and returned to Hampshire), where he did the same to his mother. Read more here→

At this point, your scribe reported his concern to the police – Ravenswood had just received a critical CQC report. We pointed out that Winchester Crown Court is as accessible from Broadmoor as from Ravenswood.

Female Detective

 

The police ‘listened’ and a few weeks later CRASH received a call from a charming female Detective Sergeant thanking him for the ‘intelligence’. Of course, she could not confirm whether he had been moved or not. (Sorry guys, I am sure there are charming male DSs out there too!)

 

 

² ‘The proof of the pudding is in the eating‘ is a very old proverb. The Oxford Dictionary of Quotations dates it back to the early 14th century. The phrase is widely attributed to Cervantes in The History of Don Quixote. 

“Our services are now safer”

Nick BDr Nick Broughton: 

Nick joined Southern Health in November 2017 as Chief Executive. He was previously Chief Executive at Somerset Partnership NHS Foundation Trust. Nick is a psychiatrist by background and has worked as a Consultant in Forensic Psychiatry since 2000.

Having commented previously on Mr Justice Stuart-Smith’s sentencing in R v Southern Health NHS Foundation Trust, it is equally important to recognise Nick’s good intentions and the enormity of the task he faces. He started well: in the words of Sara Ryan, Nick:

“Held his hands up to say ‘fair cop’ and accepted systemic failings between 2011-2016…. Broughton’s statement included open acknowledgement of the way in which we’d had to fight for justice and how wrong this was.” 

In Southern Health’s public statement after the Hearing, some of Nick’s words were even stronger: 

“Their [TJ and Connor’s] deaths were avoidable, entirely preventable and should never have occurred.” 

He also had the good grace to credit all those who have contributed to the changes at Southern Health:

“Crucial to these and other improvements is the contribution from many families and individuals dedicated to bringing about change. Whether working alongside us, or indeed as campaigning activists, their courage, dignity and insight is making a difference and deserves recognition.”

Also to his great credit a person, who attended Court, alleged that Nick told Trust’s Counsel to shut up when he asked inappropriate questions of Sara Ryan. A welcome change from the lack of ‘guidance’ to Counsel by another Director at a recent Inquest.  

Without apportioning blame, we pose the following questions about the Trust’s statement. They mainly result not from concerns about Nick’s leadership but from doubts about the ability and willingness of some senior and subordinate leaders, still in positions of influence at the Trust, to embrace change fully. For example:

  1. Is it too early to be sure the Trust is a safer place?
  2. Nick recognises the contribution, courage, dignity and insight of campaign activists and others. What steps will the Trust take to ensure all senior and subordinate leaders reciprocate by treating activists and others with respect and dignity?
  3. Many other families lost loved ones as a result of Southern Health’s version of ‘care’: some did not even have the ‘benefit’ of an Inquest. How will the Trust ensure such families do not feel ‘left behind’ by these two high-profile cases?
  4. Does the Trust agree that, although Teresa and Connor’s deaths may have been  catalysts for change, the Trust did not cause the change by self-disclosing incidents to the HSE? For example, a third party reported Teresa’s case to the HSE – almost three years after the event. What steps will the Trust take to remedy this?¹  

Regardless of these ongoing requirements (or perhaps because of them), CRASH is confident that most of those recognised in the Trust’s statement will continue to provide constructive criticism and assist transformation, wherever required. 

Our recent post about the Sentencing Hearing commended Mr Justice Stuart-Smith’s wisdom in setting a well-balanced penalty. Not being present, we were unaware of his ‘bedside manner’ (pun irresistible) but can now quote some of Sara Ryan’s thoughts

“A judgement so drenched in sense and fairness it was extraordinary to listen to. 

“The sensitivity and commitment of the Judge, Bernard, the HSE team and the media who attended (many of whom have followed the campaign over the years) were also extraordinary. Kindnesses that will stay with us. 

“Mr Justice was spot on with his ‘just and proportionate’ outcome.

“[I hope] those more widely implicated [at Southern Health] will absorb some of Mr J’s sense, fairness and integrity and now speak out.”

And that links nicely to Sir Winston Churchill’s description of the Battle of Egypt:

55274608 - statue of winston churchill in parliament square

 

“Now this is not the end. It is not even the beginning of  the end. But it is, perhaps, the end of the beginning.”

In short, our ‘work’ in respect of Southern Health has not yet ended but we hope that this week’s events mark the end of the beginning of its transformation.

 

 

 

FOOTNOTE 1 – Making life simple in the NHS!

68957027 - which arrow points to my office

 

 

Always keen to complicate (whoops) simplify life for NHS employees, from 1 April 2015 our leaders complicated simplified reporting Health & Safety incidents by splitting responsibility between the CQC, HSE and Local Authorities.

 

 

Now, rather than just ‘phone HSE (not that Southern Health did so very often), there’s a Memorandum of Understanding to read (and no doubt meetings to be held) just to decide who to contact!

Real Justice at last – £2,000,000

Stuart-Smith-J-Photo

Mr Justice Stuart-Smith

“Commendable”

“Well-balanced”

“Exactly right”

© Crown Copyright

 

 

The tabloids (aka ‘red tops’) often criticise our Judges for lenient or excessive sentences.

In R v Southern Health NHS Foundation Trust, which relates to the preventable deaths of Connor Sparrowhawk and Teresa Colvin, Mr Justice Stuart-Smith had the difficult task of balancing the gravity of the offences with the effect of a heavy fine on the treatment of future patients.  In your scribe’s opinion, Mr Justice Stuart-Smith’s sentencing was commendable, well-balanced and (in the context of the evidence presented to him¹) exactly right. He concluded:

The end result is reached by reference to my overall conclusion on totality grounds that the aggregate fine to be paid by the Trust is one of £2,000,000. In my judgment a just and proportionate outcome that marks the seriousness of the Trust’s offending, the terrible consequences of that offending, and the other material factors that I have indicated is as follows:

a. On the TJ Charge, the fine will be £950,000.

b. On the Connor Charge, the fine will be £1,050,000.

c. The Trust will pay the Prosecution’s costs in the sum that has been agreed.”

The Judge’ full sentencing remarks are available here→.

Whilst those who inhabit Pollyland and favour Crown Immunity for the NHS will no doubt have a good whinge at the level of the fine, other bereaved families, surviving ‘victims’ of Southern Health and campaigning activists, who have witnessed the dreadful events of the last six years, will realise that £2,000,000 (plus costs) is entirely justifiable.

£2,000,000 pales into insignificance compared with the vast sums of money wasted, for example: on ineffectual leadership training; legal fees in defending the indefensible; and Consultants, whose recommendations the Board generally ignored anyway.

In the context of the Trust’s expenditure during the same four years, the £2,000,000 fine is peanuts. Yes, it could have been spent on patient care but so could the £5,000,000+ Percy spent with an acquaintance on clearly ineffectual leadership training for current and future bureaucrats. Read ‘The Value of Life’ here→ and ‘The talented Mr Martin and viral impact’ here→

Percy Cleaning Loos

 

It’s a shame that the culpable CEO (Katrina Percy) did not have to stand in Court during sentencing; could not have spent a few weeks as a guest of Her Majesty; could not have been set to work for a year in a ‘Hi Viz’ jacket  cleaning Southern Health’s loos; or perhaps all three!

However, even if this could have been done legally, it would be very difficult with this printed in the Trust’s 2016/17 Annual Report (page 57):   

 

“Payments for loss of office – Information Subject to Audit”JD re KP credit 002 [Information about other officials redacted)JD re KP signature

Quite why Julie Dawes was minded to put her signature to nonsense such as, “Katrina was fit to lead” (I know!) is a complete mystery: she knew exactly how Percy had failed. HM Treasury must have misplaced their collective brain in considering it an appropriate use of public funds. ‘The Daily Telegraph’ described it as, “Scandalous Largesse.”   

¹  We have some reservations about statements made to the Judge by Counsel and about the Trust’s press statement but these are for another day. We do not wish to detract from the wisdom of Mr Justice Stuart-Smith. 

Right to Freedom & Safety

An opportunity to contribute to a change in the law!68525046 - silhouette bird go out of cage in freedom concept in sunset

The Joint Committee [of the House Lords and the House of Commons] on Human Rights  (“JCHR”) yesterday issued a Call for Evidence for its inquiry, ‘Right to Freedom and Safety: Reform of the Deprivation of Liberty Safeguards‘.

This is a rare opportunity for patients, carers and families affected  by The Mental Capacity Act 2005 and associated Deprivation of Liberty Safeguards (“DoLS”) to make their views known to a highly influential Parliamentary Committee. This probably includes many readers of and contributors to this blog and that of Dr Sara Ryan.

These are extracts from the Committee’s announcement:

“The right to personal liberty is one of the most fundamental human rights, and can be traced back to Magna Carta. Article 5 ECHR provides that everyone has the right to be free to come and go. No one may be deprived of liberty without a legitimate reason. If a person is deprived of liberty, certain safeguards must be provided; these include entitlement to take proceedings by which the lawfulness of the detention is decided speedily by a court, and the person’s release if the detention is not lawful.

“The Deprivation of Liberty Safeguards (DoLS) scheme, set out in the Mental Capacity Act 2005 (MCA), safeguards against arbitrary detention for people who are deemed to lack capacity to consent to their care or treatment. The DoLS aim to ensure that people are only deprived of their liberty when it is in their best interests and there is no other less restrictive way to provide necessary care and treatment.

“In 2014 the Supreme Court decision in the case of Cheshire West significantly widened the definition of a deprivation of liberty. The judgment has resulted in a tenfold increase in the number of DoLS applications being made in recent years. Local Authorities have struggled to cope with the resource implications of the judgment and a very large backlog of cases has built up.

“Immediately prior to the Cheshire West judgment, the House of Lords Select Committee on the Mental Capacity Act had concluded ‘[…] far from [DoLS] being used to protect individuals and their rights, they are sometimes used to oppress individuals, and to force upon them decisions made by others without reference to the wishes and feelings of the person concerned.’ They have also been widely criticised for being overly complex and bureaucratic.”

“In response to this situation the Government asked the Law Commission to look at ways to reform the legislation in this area. In March 2017, the Commission published its final report Mental Capacity and Deprivation of Liberty which called for DoLS to be replaced ‘as a matter of pressing urgency’ with a new scheme called the Liberty Protection Safeguards (LPS). On 30th October 2017 in a Written Ministerial Statement, the Health Minister issued an interim response to the Law Commission’s report, undertaking to engage in a further period of consultation and promising a final response in spring 2018. [Read the interim response here→]

“The Committee is issuing an open call for evidence from interested parties and would welcome written submissions by 2nd March on:

  • Whether the Law Commission’s proposals for Liberty Protection Safeguards strike the correct balance between adequate protection for human rights with the need for a scheme which is less bureaucratic and onerous than the Deprivation of Liberty Safeguards;
  • Whether the Government should proceed to implement the proposals for Liberty Protection Safeguards as a matter of urgency; and
  • Whether a definition of deprivation of liberty for care and treatment should be debated by Parliament and set out in statute.

Submissions should be no more than 1,500 words.”

Read more on submitting evidence to Select Committees here→. The JCHR’s prefers evidence submitted via its web portal here→.

If you do not have time to prepare a written submission, you can email any observations to CRASH via the ‘Contact‘ page. If appropriate, we will consider using it in our evidence.

CRASH has submitted evidence to the JCHR previously – on a different subject. The Committee published it and used sections verbatim in it’s Final Report. It was  a productive exercise.

CRASH’s tips on submitting evidence to Committee Inquiries

  1. The JHCR is not able to investigate individual cases but such cases can be used to illustrate specific points.
  2. Do not comment on matters currently before a court of law, if Court proceedings are imminent or if a police investigation is in progress without first seeking advice from the Clerks to the Committee: the JCHR may publish evidence anonymously in these circumstances – although you still have to disclose your name to the JCHR. 
  3. Do not publish your evidence elsewhere before the Committee publishes it. Committees tend not to consider pre-published reports.
  4. Evidence published elsewhere under the authority of the Committee only attracts Parliamentary Privilege if published after Parliament publishes it.
  5. If you publicise or publish your evidence yourself must indicate that it was prepared for the Committee.
  6. BE BRIEF (very difficult for CRASH!): include a bullet point Executive Summary on page 1 of your submission.
  7. Read carefully Parliament’s Guidelines for submitting written evidence to Committees here→ and cross-check them with instructions for the individual Inquiry – for example, the number of words allowed often varies.
  8. CRASH has always found Clerks to Committees very helpful, especially to ‘newbies’: contact them by email or telephone.

CRASH’s recommendations on attending Committee Hearings

  1. Committee Hearings are held on the Parliamentary Estate and mostly in public.
  2. Although it is rare for members of the public to be asked to give verbal evidence, it can be fruitful to attend at least one Hearing.
  3. Witnesses are named and Hearing dates announced in advance – pick a day when a person of interest to you is giving evidence. There can be opportunities to talk to  witnesses and Committee Members in the corridor before and after Hearings or during a break in proceedings: CRASH found this productive. 
  4. It is helpful if you can recognise Committee Members: information here→. Knowing names is invaluable. If your MP sits on the Committee, so much the better.
  5. Whether or not your MP is a Committee Member, inform them you are submitting evidence and, if you attend a Hearing, send advanced notice¹. They may agree to meet you.
  6. If visiting Parliament arrive at least 60 minutes early to allow time to pass through airport-type security and find the Committee Room. Queues can be especially long on Wednesdays when Prime Minister’s Questions are held.

Further Information:

Website: http://www.parliament.uk/jchr     Email: jchr@parliament.uk

Watch committees and parliamentary debates online: http://www.parliamentlive.tv

¹ To obtain MPs’ contact details in Westminster, put their given name, surname and “office” into the search engine on Parliament’s web site