Planning to Fail

dav© James Whitworth¹

In February this year, Dr Nick Broughton, CEO of Southern Health NHS Foundation Trust produced a Briefing Paper, effectively an Action Plan to reduce the number of Out of Area Placements (“OAPs”)² to circa. 20 before the end of 2019. It is already well off target.

It incuded a colour-coded graph, which we have updated from later Board Papers:

  •  Red – actual OAPs by month to December 2018.
  •  Blue – projection to March 2020 with full effects of Southern Health’s actions.
  •  Green – projection to March 2020 with full effects & housing available for patients ready for discharge.
  • Purple – actual OAPs to September 2019 and the October trend. Off the scale in August 2019! 

OAP Graph - Copy

How can the public have confidence in the management when a plan they prepare in February goes so spectacularly off target so quickly?

But Southern Health’s November Board Papers state that the Trust’s block contract for OAPs at the Marchwood Priory has been increased to 17 until March 2020 and it is currently negotiating with Elysium Healthcare for the provision of 5 female PICU³ beds in Newbury, Berkshire. (Actually, it appears to be in Thatcham!)

With the contract with Solent NHS Trust for 6 beds, the contracted total OAPs will be 28.

That’s over twice the projected figure even without extra-contractual beds! And the year to date spend of £4.8m (to Augst-end ) compares to a budgeted figure of £2.7m.

BUT BEWARE is skulduggery afoot? 

Ominous notes in Southern Health’s November Board Papers suggest that OAPs to The Marchwood Priory and Solent NHS Trust will be excluded from the future overall  total of OAPs figures. What’s more, this allegedly conforms to NHS England guidance. 

Yet, the Department of Health publishes a very simple decision tree, ‘How to decide whether an admission is an OAP.’ It states unequivocally that an OAP includes when:

“The patient is being admitted to an inpatient unit with another provider.”



Perhaps both Southern Health’s and NHS England’s CEOs are attempting to minimise the bad news ending up on the Secretary of State’s desk. They should reflect on the words of Life Coach, Lindsey Ellison:


“When you cheat on yourself, it’s the ultimate betrayal. It means you don’t value who you are. You don’t respect your boundaries. You think you’re aren’t good enough.”

We complimented Dr Broughton for his comments after Mr Justice Stuart-Smith’s sentencing in R v Southern Health NHS Foundation Trust so we should also compare his performance with undertakings he gave and his comments about engagement with campaigners. We reflect on the very positive comments he made then about members of The Forum for Justice, Accountability & Equality at Southern Health and others.:

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.”

Now the honeymoon period is over, he treats CRASH and other members of the Forum with open hostility  if we dare challenge him.

Fake News neon sign vector. Breaking News Design template neon sign, light banner, neon signboard, nightly bright advertising, light inscription. Vector illustration


We do not intend to make a political point but we nearly choked on statement by  quirky New Forest East MP, Rt. Hon. Dr Julian Lewis in a recent election flyer:

“Julian continues to campaign on , and monitor, such major local issues as mental health acute beds, community hospitals and the future of Dibden Bay.” 

Oh really? Whilst Dr Lewis was prominent in campaigning against bed closures in 2012 [Hansard 18 Apr 2012 : Column 79WH], the latest OAP figures suggest that, whatever effort (if any) he has made to this end, has been ineffectual.

Later [Hansard 8 June 2016 : Column 149WH], Dr Lewis contributed only reluctantly:

“I hesitated to contribute to this debate because I have not been involved in the
cause of the current crisis, which is about the deaths of patients being
insufficiently explained.” 

And when the excellent Suella Braverman MP sent a letter to Dr Broughton, counter-signed by other Hampshire MPs, Dr Lewis’s signature was notable by its absence.

In short, Dr Lewis worries about his own agenda but, “Hesitates” when deaths are not properly explained. Can he not see the link between bed shortages and patient deaths?




Special thanks to James Whitworth¹ for allowing use of his cartoon on a complimentary basis.




¹ Whitworth cartoons regularly appear in national newspapers as well as a wide variety of magazines including Private Eye and Prospect. He is a nationally syndicated cartoonist with daily topical cartoons appearing in newspapers from Edinburgh to Portsmouth. He also provides bespoke illustrations for Business, Marketing, Presentations & Publications.

View examples of Whitworth cartoons here:  several reference the NHS including one directly relevant to Out of Area Placements, i.e. bed occupancy.

² OAPs can be split into two categories – appropriate and inappropriate.

  • ‘Appropriate OAPs’ occur if a patient is admitted to an inpatient unit with another provider but in the same geographical area.
  • ‘Inappropriate OAPs’ occur if a patient is admitted to an inpatient unit with another provider outside of the geographical area.

Whilst appropriate OAPs are generally acceptable (arguably better) for patients and their families, the affect on Southern Health’s finances are the same.

³ PICU – Psychiatric Intensive Care Unit

Broken Willow

Fallen willow tree on the bank of a riverA recent Ipsos Mori survey on Hampshire GP surgeries revealed that residents least happy with GPs overall were those Fareham & Gosport Clinical Commissioning Group’s area, where the average satisfaction for surgeries was 75% – below Hampshire and national averages.

Top of the class in Hampshire is Petersfield’s West Meon Surgery with a 99% satisfaction rating. In summary of Hampshire surgeries’ ratings:

  •  35.5% achieved 90% and above.
  •  38.7% achieved 80-89%
  • 16.1% achieved 70-79%
  •  5.4% achieved 60-69%

Where was The Willow Group? 90th out of 93 – 4th from bottom at a miserable 59%.

The full table is available here→ .

So why is The Willow Group (a network of GP surgeries in Gosport that had caused problems for patients in the past, from “dodgy phone lines” to being unable to get an appointment) relevant to a blog relating to Southern Health NHS Foundation Trust?

Hidden away in a corner of The Willow Group’s web site:

“We are part of Southern Health NHS Foundation Trust.

Apparently, other GPs in the area were flooded with so many people wanting to change their practice that patients have been banned from doing so. In December 2018, it was reported that over 2,100 patients had transferred practices, putting a strain on the system. Two of eight practices in the town had already had to close their registration lists, as they struggled to cope with increasing numbers. Some residents believe that many transfers had been away from the Willow Group – Read more here→.

One has to ask why Southern Health – the ‘Broken Trust‘, with long-standing unresolved issues in its core specialism of mental health and learning disabilities – wants the added burden of a troublesome GP Practice Group.

Question Mark 2


Would it not be in everyone’s interest for Southern Health to dispose of the Willow Group to concentrate on its core business?

On the NHS ‘Reviews and Ratings‘ web site, the Willow Group is rated only two stars.  Comments here include [partly abbrev.]:




Emoticon face with symbols on mouth


“Receptionist rude and unhelpful, no dignity or respect for elderly patients.

“Visited in August 2019. Posted on 14 August 2019.”


“Every time I try to phone, I get put in a queue whilst I wait for my ‘care navigator’ … get bored and just go to surgery. Sometimes with a sick child strapped in a buggy, to cancel their jabs that week because, and this will tickle you, I don’t want to waste anyone’s time. Today’s debacle was the usual ‘you are P8 in the queue so I set about housework knowing this was going to be a long one. I got down to P3, the house was immaculate by now, when the phone just rung off. End of. Called back, P9. No way. I just wanted to book some jabs for my son. That’s all. 20 years ago it was a phone call and job done in 2 minutes tops. Visited in June 2019. Posted on 13 June 2019.”

“Left the surgery in tears!! The Dr I saw was very rude and made me feel like a failure!! I actually left his room in tears and the chemist arranged for someone to pick me up because I was so upset. Disgraceful considering I’m also depressed. Visited in May 2019. Posted on 19 June 2019.”

“My wife called surgery as requested was given an instruction that she would be called back with[in] 48 hours. Nothing heard from surgery. Called again and yet again told she would be contacted – still in pain still waiting for a reply. This service is disgraceful and needs fixing. So much for the promises of improvement given.
Visited in February 2019. Posted on 28 February 2019.”

Additional comments here, including the ‘Big Shoes’ story.  Interestingly, this website suggests that, in the Willow Group, out of 62 stories told, none have led to changes.

lack of freedom



Patient told by GP to buy bigger shoe!


“Partner just undergone complex surgery on foot which could have been avoided if doctors/staff had acted much sooner. She rarely visited a surgery but few years ago a foot began to swell and toe distended to one side. She visited Waterside only to be told by the GP to buy bigger shoe. This is the absolute truth! She came away appalled & dejected … the surgery should hang it’s head in shame.”

“For nearly 5 weeks I have been desperately trying for an appointment for a medical examination to renew my commercial drivers’ licence. I have been promised call backs, emails and nobody has contacted me to set up a time. My licence will expire in a couple of weeks and I will lose my job, but the Willow Group do not care. It is impossible to get through to speak to someone. On the times I have been into the surgeries to try and get the situation resolved, I am told by the reception staff that they don’t usually work there and they are not sure how it works…. They are going to cost me my job. As far as I can see, the Willow Group needs to get some staff that know what’s going on. At the moment, they are not fit for purpose.”


Young beautiful woman in red dress looking to blue sea and fiery sunset

“‘Diva’ doctors threaten patient care.”¹

We have reported on the culture in the NHS previously here→ – and elsewhere.

New research commissioned by no less that the General Medical Council has identified five problematic subcultures amongst doctors in leadership roles:¹ 

Diva subcultures – powerful and successful professionals are not held to account for inappropriate behaviour. Left unchecked, divas become viewed as untouchable, and colleagues accommodate them and work around them.”

It was easy to find an image of a female diva but it is likely that are outnumbered easily by male divas. The other four subcultures are harder to illustrate! 

Shouting to a womanFactional subcultures – disagreement becomes endemic, and the team starts to organise itself around conflict. Those in dispute look for support and loyalty from colleagues, and staff may seek to avoid working with those on the ‘other side’.”



Patronage subcultures – arise around influential leaders who have social capital in the form of specialist knowledge, professional connections, high status, respect and access to resources.”


Embattled 4

Embattled subcultures – where resource has been inadequate, and unequal to demand, practitioners eventually become overwhelmed. They feel besieged by the unmet need they see in patients, and may show signs of chronic stress such as short temper, anxiety and burnout.


The silhouette of a lonely man

Insular subcultures – some units become isolated from the cultural mainstream of a larger organisation, resulting in professional practice or standards of care that deviate from what is expected. The isolation can be geographical or psychological.”

And of course these subcultures aren’t mutually exclusive. They may often co-exist alongside one another in the same organisation.¹ 

The full GMC Research Paper by Dr Suzanne Shale is available here→²

We believe that some of these features could be applied equally to many in NHS leadership roles, not just doctors.

I struggle to categorise Southern Health NHS Foundation Trust and may be able to identify features of all five subcultures. For now, from personal experience, we know that there are divas, who are not held to account for inappropriate behaviour and already consider themselves untouchable.

Would anyone like to suggest the subcultures that exist at Southern Health! If so please use the reply facility here→


¹ Health Service Journal: article by Annabelle Collins with comments by readers here→ . (Please note that the full article and comments are available by subscription only.)

² General Medical Council.

Mouth one way, belly ‘nother way


Old Australian Aboriginal description of a hypocrite:

Mouth one way, belly ‘nother way.

SH Notice2




Which brings us to a sign spotted at Southern Health NHS Foundation Trust’s HQ recently.







This from a Trust:

  • Whose Chair is accused of intimidating a patient’s representative at a Council of Governors meeting to the extent that the patient felt too intimidated to stay to ask an important question relating to his ‘care’. Read more→
  • Whose CEO is accused inter alia, of damaging patients’ health and discrimination under section 1 of the Disability Discrimination Act 1995 (as amended).

SH Notice1


How can Southern Health staff be expected change the way they think and act about mental health if their Chair and CEO set such a great example!


Dormitory Wards


Another of Southern Health’s dark secrets was revealed recently. It is 14th in a list of English mental health Trusts with highest number of dormitory wards and beds. Details→¹

Lunatic Asylums come to mind!


And, in respect of out of area placements (“OAPs”), where families have to travel afar to visit their loved ones, Southern Health NHS Foundation Trust was exposed recently as 7th on the list of mental health Trust having the highest number of inappropriate OAP’s². Whilst these are ‘inappropriate’, the definition of an OAP is:

“The patient is being admitted to an inpatient unit with another provider.”  

This reflects the fact that, whereas inappropriate OAPs affect patients and their families, all OAPs have financial implications. Southern Health admitted: 

“The £1.1m deficit remains broadly the same as the previous month and
continues to be attributed mainly to out of area placements.”

It appears that Southern Health is massaging OAP figures by excluding contracted beds with Solent NHS Trust (6) and The Priory Southampton (10) from OAP figures because, “These beds are within our catchment area…” What part of HM Government’s ‘Out of area placements decision tree‘ does Southern Health directors not understand.

Whilst it is great for patents and families to have OAPs within Southern Health’s catchment area (especially those lucky enough to be admitted to The Priory), the affect on the Trust’s deficit remains. 

To adapt a well-known adage attributed to Benjamin Disraeli, in our opinion:

“Southern Health is an organised hypocrisy.”

And, for balance, patients can be guilty of hypocrisy too. I suspect the person who returned £250.00+ of medication to a local pharmacist claims the NHS is underfunded.

Wasted Scrips


In 2017-18, there were 11,619 community pharmacists in England.³

11, 619 x £250 = £2.9 million 



And that’s just one patient at one pharmacy. Apparently, a significant percentage arises from patients’ ticking every box on a Repeat Prescription form rather than tick just the items they need – and GPs do not cross-check diligently

A report by the Department of Health estimates that unused medicines cost the NHS around £300 million every year, with an estimated £110 million worth of medicine returned to pharmacies, £90 million worth of unused prescriptions being stored in homes and £50 million worth of medicines disposed of by Care Homes. 


¹ Source: Health Service Journal

² An inappropriate OAP: when a patient is treated out of their local area. [Media Office, NHS England and NHS Improvement – 26 June 2019]


Bored Meetings & Peter Drucker

Failed BusinessCRASH sat recently through two interminable Southern Health NHS Foundation Trust meetings – a Board Meeting on 14 May and a Council of Governors Meeting (“CoG”) on 28 May 2019: meetings which previously took place on the same day of the month. Result?

  • Fewer governors attend Board Meetings to judge how Non-executive Directors hold Executive Directors to account: that’s the Governors’ job! Just one there on 14 May.
  • Fewer members of the public attend both meetings to pose challenging questions.

This was entirely predictable: many governors and members of the public have full time jobs and other commitments. Most find it easier to dedicate one day a month to Southern Health rather than two three-quarter days (including travelling).

Also, details of the CoG were not published until it was too late to file advanced questions so only two members of the public attended. Even some staff at Trust HQ did not know about it until the day of the meeting.”



CRASH was one member of the public present at the CoG: the other (mentally unwell person) with a question to ask at the end, left half-way through feeling intimidated by the Chairman of Governors attempt to intimidate CRASH.

Naturally, the Lead Governor kept shtum, doing nothing to ‘protect’ the public.



The Japanese MD, Nagatomo-san, who pulled CRASH up the slippery ladder at Kawasaki without  much resistance!), was a disciple of legendary business guru Peter Drucker. Four of us got one of his books for Christmas – not an easy read so we can’t recall much!  A bottle of Faustino I Gran Reserva Rioja would have been preferred.

However, coincidentally last week, we came across a quote attributed to Drucker:

“Culture eats strategy for breakfast.”

Also the words were used and embellished in an article about the NHS in ‘The Journal of the Royal Society for Medicine’ headlined “Understanding organizational culture in reforming the National Health Service: it includes (amongst other robust statements) the following comment by a US hospital CEO about culture needed to transform the NHS:

“Culture eats strategy for breakfast, every day, every time”

The whole article by Prof. Huw T. O. Davies BA MA MSc PhD Hon MFPHM¹, published in November 2001, is compelling reading for those attempting to transform NHS Trusts. Read more here→

Yet Southern Health’s motto appears to be:

‘Strategies eat culture for breakfast, every day, every time.’

CRASH’s peers share our cynicism and came up with further variations :

“Strategies eat culture for breakfast meetings, every day, every time.” 

“Meetings eat everything, every day, every time.” 

Or (unrelated):

“We exist to talk about stuff, not to really do anything.”

To test the theory, CRASH carried out a word count on the papers of a random Southern Health Board Meeting using the search facility:

Strategy 61 plus strategies 5 = 66.

Culture 11 (no plural) plus cultural 2 = 13.

If  one analyses (or drills down as the NHS prefers to say) the results for culture, the figures are even more enlightening. Of the 13:

  •  3 are attributed to guests at the meeting.
  •  6 appear in the Trust’s risk assessments – because, “There is a risk that we fail to develop and maintain a culture….” or similar.
  • Only 4 are attributed to comments by Directors.

Most telling is this extract from the papers:

The Trust has liaised with other Trusts who have successfully implemented violence reduction initiatives and found that: setting targets for reduction does not work and promotes under reporting of incidents initiatives not supported by a quality improvement methodology will not be sustained in the long term as they do not embed and support cultural change.

This may seem a bit like gobbledegook but, if our interpretation is correct, it is somewhat bizarre that Southern Health, an organisation trying to introduce Total Quality Management, seems more interested in strategies than culture.

Low angle view of cricket umpire signalling six runs against blue sky


One could say of Southern Health NHS Foundation Trust:

“Strategy hits culture for six every day, every time




Southern Health claims to be improving community services yet the Basingstoke ‘Gazette‘ reports that it is scrapping the majority of drop-in clinics in Basingstoke for young Mums and babies!” Read more here→


We all know that babies are at the most vulnerable stage of their lives – so scrapping the majority of drop-in clinics really is a great idea, Nick, especially when the Trust  website and notepaper bear a logo claiming to put, “Patients & people first.” And the ‘Our Vision and Values‘ page of the website claims it as a core values.



A decision made by bean counters? Surely not.



Which gives us a great opportunity to close by paraphrasing Drucker again.



“Money eats patients for breakfast, every day, every time”



Back in the 1970/80s, little did we know that Drucker would be so useful 40 years’ later!When will Southern Health NHS Foundation Trust transform its culture?


¹ Honorary Member, Faculty of Public Health Medicine


The Secretary of State’s Desk

Woman businesswoman under stress missing her deadlines


“The rational response of an appointed NHS CEO is not necessarily to improve the long-term performance of the hospital, but instead to minimize the amount of bad news that ends up on the Secretary of State’s desk.”



This is just one conclusion to academic research,  ‘The Impact of CEOs in the Public Sector: Evidence from the English NHS‘ published by the Harvard Business School.

The paper, available here, authored by leading academics Dr Katharina Janke
(Lancaster University), Prof. Carol Propper (Imperial College & University of Bristol) and Prof. Raffaella Sadun (Harvard Business School) is supported by detailed, statistical analysis, which mere mortals would not pretend to understand.

The conclusions are enlightening and should be essential reading for the Secretary of State for Health & Social Care, his Junior Ministers and officials, along with the Boards of NHS Improvement and the Care Quality Commission.  Essentially:

“We find little evidence of CEOs being systematically able to change the performance of these organizations. We also do not find evidence that a change in CEO brings about an improvement (or even just a change) in performance.”

The paper proffers two possible explanations [abbreviated and paraphrased]:

“Lack of CEO effects is consistent with top managers chasing political goals, not policies that might improve hospital performance. The rational response of an appointed CEO is not always to improve long-term performance, but to minimize the bad news landing on the Secretary of State’s desk: this may explain why there is a CEO effect in remuneration, unassociated with observed performance, but with receiving public honours. The political nature of the NHS may lead to negative sorting (reluctance of high performers to seek CEO appointments). 

“Hospitals are large complex organizations, in which highly trained (and hard to monitor) individuals run separate, interconnected production processes. Top Management may find it difficult to engage in co-ordination and getting a large number of actors, who traditionally have not worked together, to work co-operatively. A possible interpretation of our finding is that the organizational inertia of a large hospital is often too strong for a CEO to impact performance.”

These conclusions are remarkably similar to expert (unscientific) analysis of Southern Health’s recent reply to a letter from Suella Braverman MP to the Secretary of State. A press release and Southern Health’s response are available here→.

The expert analysis is here→.  The similarities with the conclusions of the Harvard Business School paper are clear. For example [abbreviated and paraphrased]:

“I am also mindful that there is a political and PR exercise at play here.

“[Directors] have forgotten that the letter was addressed to the SoS. They address the points made as though it were directed to them as criticism and write what I feel is a very defensive letter. A better approach would have been to build on what was said and commit to what they could do with £5m to invest in the areas identified, or indeed suggest where the outcome could be improved by investing it differently. They simply don’t see this opportunity; they see this as a threat to their position and authority. Clear arrogance on their part I would suggest in that they know best. 

“They are dismissive about the points on GP training and the deployment of Medical Examiners essentially saying its someone else’s job to deal with those. Everyone is aware these are not Trust specific issues, indeed the work requires all parties to play their part and work as a team. Saying it’s for someone else to do is very much old school “pass the parcel” mentality which indicates there is much more to do to change the culture.

“Overall, the response doesn’t say a lot. It’s all aspirational. Very little is tangible in terms of specific results that can be expected to be seen by a specific time. 

“The first two pages of the [Trust’s]  reply are all spin and waffle. It tells us very little about what the customer can expect by way of improvements. It tells us there’s a new board, a focus on training staff in a QI methodology, a focus on improving patient and carer engagement, a new organisation structure and an improved culture. No detail as to what this will mean to the customer.  

Regarding the second explanation, we know Southern Health is a large complex organization, in which hard to monitor individuals who run separate, interconnected production processes. It is difficult to engage in co-ordination and getting a large number of staff , who traditionally did not work together, to work co-operatively. As we have said before, transforming an NHS Trust is more difficult than turning around an ocean liner.

When will the Secretary of State’s desk look like that of Russian Tsar Nicholas II in his office in Livadia Palace, Crimea – 4 family photo’s, 6 sheets of paper and a large tome?

figure of tsar Nicholas II in Livadia Palace


Triangle of Care

The combined hands, are forming a triangle

The Triangle of Care™¹ is not a difficult concept – it’s just common sense. Yet how many Mental Health & Learning Disability Consultants and other clinicians ignore it?

We reported the Inquest into Ellie Brabant’s death just three months ago. Yet this month, we attended the Inquest into Maria (‘Joey’) Duarte’s death. She died at the same Southern Health NHS Foundation Trust unit (Antelope House) just 2.5 months after Ellie.

Ellie and Joey had two things in common – extremely supportive families – and the same Consultant Psychiatrist, Dr Obed BekoeYet were the families involved in their care?

NO! Dr Bekoe admitted he had not engaged with Joey’s family because he felt she had capacity and she had not requested it.

Dr Bekoe: As a Consultant Psychiatrist, an Expert Witness, an RCPsych Examiner, an Educational Supervisor and a Medical Appraiser, exactly what part of the Triangle of Care™ do you not understand?

Patients don’t have to ask about family engagement: they should be offered it. Capacity in a patient with suicidal thoughts should not be assumed.

Best practice is clear and unequivocal:

Triangle of Care 6


“In line with good practice, practitioners should routinely confirm with people whether and how they wish their family and friends to be involved in their care generally, and when looking at information sharing and risk in particular.”²



In short, a patient’s capacity is irrelevant – clinicians should discuss family engagement with patients routinely – not wait for patients to ask. Even in respect of capacity, good practice suggests:

“If a person is at imminent risk of suicide there may well be sufficient doubts about their mental capacity at that time.”²

Is this not common sense too? In CRASH’s opinion, for example, there must be doubts about the capacity of anyone, who sits on a railway bridge for five hours threatening to throw himself off – much less a person known to be mentally unwell. Yet, another Southern Health Consultant Psychiatrist thinks not. 

The Consensus Statement on Information Sharing

Unrelated directly to The Triangle of Care™, the Department of Health, Royal College of Psychiatrists and others issued a ‘Consensus Statement‘ in January 2014 as part of the suicide prevention strategy for England. It aimed (inter alia) to improve information and support for families concerned about a relative, who may be at risk of suicide.

The General Medical Council, Nursing and Midwifery Council and Health and Care Professions Council confirmed that the advice and policies set out in the Statement are consistent with their guidance on consent. The Information Commissioner’s Office confirmed that it is consistent with the Data Sharing Code of Practice. Read more→Conceptual mental health or positive thinking triangle arrow word cloud isolated background. Collage of optimism, psychology, mind healthcare, thinking, attitude balance or motivation text

So why, five years later, are some Members of the Royal College of Psychiatrists not compliant with good practice in this respect and why did Southern Health only learn about it in 2019? 



There were multiple other similarities between Ellie and Joey’s deaths, for example:

  • The same Responsible Clinician, Dr Obed Bekoe.
  • Total failure to work with a very supportive family.
  • Identical ligature point – top of a door.
  • Similar ligatures – clothes.
  • Observations, when expressing suicidal thoughts, too infrequent and carried out by junior staff.
  • Allowed leave from Antelope House despite concerns about their well-being. (Joey was a voluntary patient but could have been sectioned.)
  • Both passed like parcels between various Southern Health Teams and multiple Responsible Clinicians without proper handovers/communication/care plans/risk assessments.
  • Questions about medication.
  • Failure on at least one occasion to record suicidal thoughts.

There were a couple of common problems indentified at the Inquest:

  • Junior staff blamed rather than senior staff taking personal responsibility (with the honourable exception of the male senior nurse, who gave evidence in person).
  • A page from shift handover notes missing from Coroner’s bundle – revealed by the senior nurse. Yet again Southern Health lacks diligence in preparing Inquest documentation … and yet again the moment passes without any consequences for them. A deliberate act or simply incompetence?

In short, total failure in clinical management, family engagement and Inquest preparation.

side-way-smiley-face-emoji (rediced) 2

On a positive note, Southern Health officers and staff  were soberly dressed and conducted themselves appropriately at Joey’s Inquest. There was no laughing and joking as witnessed at Ellie’s Inquest.


Lynne Hunt, Chair of South Health’s Board of Directors, said:

Pic by Samantha Cook Photography, 30th March 2016. Portraits taken of board members at Dorset HealthCare University NHS Foundation Trust, Sentinel House, 4-6 Nuffield Road, Poole BH17 0RB.

Our own investigations and the coroner’s conclusions revealed missed opportunities. Joey’s death has led to meaningful and ongoing changes to make Antelope House, and indeed all our whole trust, a safer place.”

All good stuff (and some improvements were not ‘quick fixes’) but Joey’s family could well ask:

“What steps were taken to implement the simpler improvements, which were clearly required immediately after Ellie Brabant’s death?

“The Board did not report any of the clinicians involved in Ellie’s death to their regulators? Will the Trust report those involved in both deaths to regulators or – failing that – will they be disciplined internally, retrained and supervised?

Elsewhere, Greater Manchester Mental Health NHS Foundation Trust received a second gold star for its commitment to the national Triangle of Care™ initiative. (Alarmingly at the time, only one of four mental health trusts in the country to do so.)

West London Mental Health NHS Trust committed to putting it in place during 2018.

And finally, on the website of Kent and Medway NHS and Social Care Partnership Trust:

“The Triangle of Care™ guide was launched in July 2010 by The Princess Royal Trust for Carers (now Carers Trust) and the National Mental Health Development Unit to highlight the need for better involvement of carers and families in the care planning and treatment of people with mental ill health.”

To paraphrase the Princess Royal herself, after nine naffing years the Triangle of Care™ is still not in place at Southern Health or nationally and after naffing five years, Consultants are not compliant with good practice set out in the Consensus Statement.   

And here’s a couple of images found on the website of Avon & Wiltshire Mental Health NHS Partnership NHS Trust – awarded a second star in 2015:Triangle of Care 2


Triangle of Care 3













When will Southern Health NHS Foundation Trust achieve similar recognition?


¹ Triangle of Care – Trade mark number UK00003054307 (Carers Trust)

²  Consensus Statement on Information Sharing

Rest Day

Funny golden retriever labrador puppyÊlying stretched at poolside

Madcap 2019 to date dealing with Southern Health, helping complainants and holding the Board to account, so much so that writing a blog post constitutes a rest day!

So, we thought it should be a lazy day too – simply re-blogging others’ efforts. But before we do, the latest ‘news’ from Southern Health.


SuellaHoC(2) Reduced

14 February 2019: excellent MP, Suella Braverman (née Fernandes) and four fellow Hampshire MPs¹ co-sign a letter to the Secretary of State for Health & Social Care, Matt Hancock MP, expressing continuing concern about Southern Health. She outlined ways in which she felt the Secretary of State could provide more support. Read more here→.


Southern Health’s reply (available here) is viewed as all talk and no action: Suella’s letter backs fully the main thrust of a paper put to the Board on 1st February 2018 and a Position Statement in November 2018, both by well-informed experts by experience.

Considered opinion by one of these experts is that Southern Health’s Chair and CEO have completely overlooked that Suella addressed the Secretary of State. They address her points as if directed at them as criticism and respond with a very defensive letter. A more positive approach would have been to build on what was said; commit to what they could do with £5m to invest in the areas identified; or indeed suggest where the outcome could be improved by investing it differently. Another opportunity missed!

They simply don’t it as an opportunity, they see it as a threat to their position and authority. Clear arrogance on their part – they know best.

British Association of Social Work Conference 

“Safeguarding and human rights: what do families need from social work? What do we need? Easy peas: thoughtfulness, understanding, knowledge, integrity, action, transparency and honesty.” [Dr Sara Ryan]

And we need a dose of this in NHS mental health and learning disability services too².



The Minister of State for Health & Social Care, Caroline Dinenage MP (named here) is one of the Hampshire MPs, who signed Suella Braverman’s letter to the Secretary of State.


Has Matt Hancock based his new NHS IT plans on “Yes Minister”?

Computer Wiring


Question? What would Sir Humphrey do, having spent over £11.4 billion on the notorious National Programme for IT (NPfIT), described as a major ‘push’ to improve NHS IT systems, only to dismantle it as one of the mostly costly and troubled projects in public sector IT history? [Analysis by University of Cambridge academics here.]

© 2016 Tads India


Answer? Create a new departmental unit (NHSX); require up to £13bn in IT investment over 5 years; employ more civil servants; give different job titles to existing officials; and/or create new job titles at higher pay grades! YES MINISTER!


Somebody using a Mencap supported living service wants to take Mencap to Court using Mencap’s legal support service. Conflict of interest and PR Campaign? Interesting and thought-provoking comment and potential solution here→.

SEND (Special Educational Needs and Disabilities)

The SEND Plan assists children and young people’s ability to learn. Typically, it helps those up to the age of 25 with difficulties, including:

  • Behaviour or ability to socialise, such as struggling to make friends, for example those with autism or Aspergers.
  • Reading and writing, for example those with dyslexia.
  • Ability to understand things, for example those with moderate learning difficulties.
  • Concentration levels, for example those with ADHD.

Naturally, children with physical disabilities are included too.

However, the SEND law is alleged to have been poorly understood and inadequately implemented in schools. Unsurprising perhaps when the SEND Code of Practice runs to 292 pages. Apparently, schools often sanitise plans, for example by replacing ’cause for concern’ with ‘barrier to learning’… read more. Just as the NHS uses ‘learning opportunity’ to describe a ‘cock-up’! The old duck-billed platitudes again!


¹ Caroline Dinenage, Sir Desmond Swayne, Maria Miller and Ranil Jayawardena.

² More to come on ‘integrity’ in the NHS.


Counting sprouts

13126964 - fresh green brussels sprouts isolated on white backgroundBizarrely, it is alleged that Southern Health is recommending COUNTING VEGETABLES as a therapy for depression. Being the festive season, sprouts should be readily to hand!

Sarah Ghafoor had suffered with depression for around 20 years and had previously made attempts to take her life. However, during an Inquest into her death, her family alleged she had been told by mental health professionals to COUNT VEGETABLESwhen she felt overwhelmed by her son, Ben’s death.

Sarah was prescribed a cocktail of anti-depressants and was seen by mental health staff at Southern Health as she struggled to cope with Ben’s death. She made three attempts to take her own life after his death on March, 12 2018. Her daughter-in-law told the Court Sarah had just wanted ‘someone to help’ but had been let down by Southern Health:

“She needed someone she could phone, not someone who told her to count vegetables – her son had died.

“I called Southern Health begging for help and they were horrific to me on the phone. If there were like that to me, how would she have felt?”

Read more here→

Another of Southern Health’s bright ideas for therapy (this time in conjunction with Southampton City Council) is CLEANING COUNCIL HOUSES. This came about after we proposed two proven outdoor therapies, to which a CMHT Manager responded:

Girl Plumb Dirty Toilet


“I thought about the supported housing projects in Southampton and many [with] no cleaning services. I was wondering if we could work together with Employment support to engage individuals in recovery to do some of this work.” 




So CLEANING COUNCIL HOUSES is apparently good for patients’ self-esteem. Cleaners we know laughed at the thought – it is more likely to have the opposite effect. Also, if patients have understanding employers, who allowed them time to recover from mental illness and the employers discover their employees are doing cleaning work for the Council, they will assume the patients are fit to return to work – if only to clean their workplace. I also suspect Southampton Council’s motives – cheap (or free?) labour. Sounds more like modern slavery to me! I wonder if they get paid at all? 

Now for ideas for open-air therapy proposed to Southern Health by CRASH:


Beach Cleaning


Not our original idea, but we were extremely impressed by Marine Biologist, Emily Stevenson, who appeared on Sky News on 22 September 2018 to promote her Beach Guardian initiative in Cornwall to tackle the scourge of plastic on our shores. Business owner Rob Stevenson and his  daughter Emily set up Beach Guardian originally in 2017.


Rob and Emily soon recognised that the region’s mental health was also in crisis with time off work due to mental health issues doubling in the past year, to the point where NHS figures show that Cornwall has seen one of the biggest increases in the country. Rob and Emily saw a way of addressing both problems with Beach Guardian. Read more→

And what’s more, CRASH received a potential offer of external funding for this therapy.




Or if fresh air on the beach doesn’t suit – go into the New Forest and walk with Alpacas. Read more here at footnote² →.




So which do you think is more beneficial to mental health patients?

Walk in the forest and on the beach – or counting sprouts and cleaning Council Houses!

Operation Scorch


Fire and flames.

Can you help detectives investigating the rape of a teenager in Southampton?

On Sunday, 2 December 2018, an 18-year-old woman was assaulted between 11pm and 11.50pm in Riverside Park just off of Woodmill Lane, Southampton.  Her name cannot be revealed for legal reasons. Read more here→.

So why, you may ask, it this relevant to Southern Health? Unforgivably, there is an alleged rapist at large as a result of its failure to report the alleged rape of a patient.

The Inquest into the death of Ellie Brabant, revealed that she returned to Antelope House, alleging she had been raped. Southern Health failed to report the allegation to the police.  CRASH believes the police would like to eliminate Ellie’s alleged rapist from their inquiries into the latest incident. It is only a possibility but such inquiries might also lead belatedly to an investigation into Ellie’s alleged rapist.

The Coroner’s Regulation 28 Prevention of Future Deaths Report on Ellie’s death identified this. The report by the charity Inquest records also that Southern Health:

  • Contaminated the scene of Ellie’s death by allowing her room to be cleaned before the police had finished their work.
  • Withheld a key document from the Coroner¹, Counsel for the family, and (to his great embarrassment) Counsel for the Trust. The Coroner’s diligence led to this being remedied on the last day of hearing verbal evidence: the document was key. 

Even more alarmingly sources close to Hampshire Constabulary inform us that Southern Health did not make a police report even after receiving the Coroner’s report.

Therefore, if you have any information, material or CCTV footage that can help in either incident, please dial 101 quoting Operation Scorch (Crime Number 44180450724). You can email too using these references We are sure it will be well-received. Please read on for more details.

Police Rape Map


For the assault on Sunday, 2 December 2018, the police have issued the route they believe the man they are hunting may have taken. Larger image here.

If any readers were in this area on 2 December and/or have any other information, they should contact the police.



The Coroner’s Regulation 28 Report and the charity Inquest’s report on Ellie Brabant says much about alleged improvements at Southern Health.

Even in the era of Katrina ‘Teflon’ Percy, I don’t recall, for example:

  • An informal patient telling clinical staff she had been raped, whilst away from the unit, and the Trust (?) not reporting it to the police. ***
  • An informal patient allowed to continue taking leave when she was returning high on drugs and/or drink and admitting to prostituting herself to raise the money.
  • The Trust (?) failing to secure the scene of an unexpected death before the police had finished their work. ***

I do recall late disclosure of evidence being criticised by a Coroner but, on this occasion, it was only the diligence of the Coroner, who discovered evidence on the last day of hearing, that the Trust had withheld a vital document. ***

22032231 - grumpy old judge in extreme wide angle closeup with hammer and wig*** Does failing to report alleged rape; failing to secure the scene; and withholding a key document from a Coroner, fulfil CPS Charging Standards for Perverting the Course of Justice² or Misconduct in Public Ofice³?


The charging decision is made by the police, working with the Crown Prosecutor. But, everyone can form an opinion⁴ using the information and links in footnotes 2 & 3. 

Finally, a reminder that BBC South Today’s report on the Inquest, is available here→.  

And for those who came to the Southern Health saga late, the BBC documentary ‘Broken Trust’ is now available too – here→.

¹ Senior Coroner, Mr Grahame A Short

² Perverting the Course of Justice is a common law offence committed when an accused:
does an act or series of acts; which has or have a tendency to pervert; and which is or are intended to pervert; the course of public justice. The course of justice starts when:
an event has occurred, from which it can reasonably be expected that an investigation will follow. The Trust knows there will be an Inquest and a police inquiry after an unexpected death so the question of reasonable expectation does not even arise. 

³ Misconduct in Public Office is a common law offence, which is committed when: a public officer acting as such; wilfully neglects to perform his duty and/or wilfully misconducts himself; to such a degree as to amount to an abuse of the public’s trust in the office holder; without reasonable excuse or justification. It normally includes elements of dishonesty, concealment and cover-up. It is often used when an alternative offence does not give the Court adequate sentencing powers.

DISCLAIMER – facts around the incidents described in this post are attributed (as shown) to the Coroner and Hampshire Police. Related observations are opinion only and should not be interpreted as implying any misconduct on the part of any individual persons or persons. That is a matter for the CPS, police and/or relevant Regulators.