Stock-taking

Last week, The Medical Practitioners’ Tribunal published its ‘DETERMINATION: Facts’ relating to Dr Valerie Murphy – Connor Sparrowhawk’s Consultant Psychiatrist at Southern Health the time of his passing in 2013: Read Murphy-FACTS here.

And a graphic description of the experience of the key Tribunal witness, Connor’s Mum, Dr Sara Ryan here – posts dated 7th to 18th August, 2017 – with perhaps more to come.

Coincidentally, Southern Health’s ‘Team Brief June 1917 came to CRASH’s attention last week too – an ideal time for stock-taking improvements in the last four years. Here are some extracts.

June Team Brief 2

 

June Team Brief 1 - reduced

So, four years’ after Connor’s passing and despite all the highly critical reports, Southern Health remains unsafe for patients – especially vulnerable children, who are at risk of “Significant harm.” It is worth restating:

“Children are at risk caused by inadequate staffing level and IT support systems, which may result in significant harm in the MASH – Multi Agency Safeguarding Hub environment.”

June Team Brief 3It is difficult to escape the conclusion that operational and financial problems caused by outsourcing 29 beds have their roots even before 2013, when Southern Health used distinctly dodgy statistics to justify closing Woodhaven Hospital. The Trust’s methods were described as “slippery” and Katrina Percy and Dr Lesley Stevens named specifically. Read the parliamentary debate here – Dr Julian Lewis – Hansard 18.04.12.

June Team Brief 4

Encouraging that only 15% of staff had completed their appraisal, compared to 34% at the same time last year! And why does Southern Health only “invite” staff to book an appraisal – I’m sure poorly-performing staff will jump at the chance to be criticised on their record. In the ‘real world’ all staff are told when and where to attend an appraisal.

Sick Bag 2

 

And finally – pass the sick bag.

 

 

June Team Brief 5

“We are sad to bid a fond farewell to Lesley Stevens …. “

 

 

Read the full Team Brief here→

Call to Action

Call to Action V3COMMENT ON SOUTHERN HEALTH’S NEW COMPLAINTS POLICY

Recently, we wrote two blog posts with references to Southern Health’s Complaints Process – The Scales of Justice and Kangaroo Court. At the Trust’s request, CRASH submitted a review of Southern Health’s procedures, in particular on inconsistencies with official reports and guidance: download here: Complaints Investigation Report.

We received the draft of Southern Health’s ‘new’ complaints policy with just two working days to comment! There are two draft procedures and a feedback form: available here→ Policy Review Form; SH NCP10; and SH NCP 11v3.

Surprised nurse v1

Surprise, surprise

The Trust had completely ignored CRASH’s report.

And all the official reports and guidance therein. 

 

CRASH responded immediately [abbreviated]:

“I will circulate your email and attachments [to the Forum] but it is unreasonable to expect any of us to respond by the end of the month.

“In any event, I can tell from point 10 ‘Supporting References’ that the review is inadequate. Setting aside that you received my comments relatively recently, you have not referenced the Dale Report, the Francis Report or the Shipman Inquiry.

“The [John] Dale Report is specific to Southern Health and its complaints process, authored by the Chair of the NHS Complaints Manager’s Forum, dated 30 January 2017 since when it has been in the Trust’s possession – yet, despite the credibility of the author, you appear not to have used his report in reviewing the policy.

“Within the Dale Report [is] reference also to relevant sections of the Francis Report and, from there, the Shipman Inquiry. You could have taken these into account without my paper.

“I cannot comprehend why the Trust has arranged six 3-hour workshops as part of a website review but none whatsoever on complaint processes. The latter (if compliant with the law of natural justice, relevant guidance and authoritative reports) will have a far greater impact on patient safety than an improved web site.

“I hope you and your colleagues ‘take this on board’: I would recommend that you extend the deadline for feedback until the end of August.

As a result, the Trust extended the deadline by a generous week. In a phone conversation, they claimed also that staff did not have the opportunity to see and challenge an investigation report, yet the draft states unequivocally:

The response will first need to be returned to service. It will need to be reviewed, and agreed by the investigating officer, commissioning manager and any staff named in the complaint and/or who have contributed to the investigation.

So, at the time of writing, the Trust still has no intention of giving complainants the same opportunity as staff – a fundamental part of a fair process, the law of natural justice and Article 6 of ECHR. It was a specific recommendation too of The [John] Dale Report, which has been in the Trust’s possession for circa. six months.

Despite the deadline, CRASH still urges service users and families to let Southern Health have their comments on the draft policy by email: click here. More pressure (even after the deadline) might make them think twice – though don’t hold your breath!

Here is some (abbreviated) feedback from others:

“Reading through the documents made me remember why I gave up playing golf. It has an extremely “user – unfriendly” set of rules and regulations!” [Carer]

“I am sure [Ombudsman] would want to know why none of the recommendations have been included in a new policy. What a waste of money … it all goes to show what a waste of time this has all been.” [Bereaved family in Dale Report]”

“I will not be giving feedback for reasons that perfecting a useless system is a waste of time – it has little to do with improving quality and satisfying customers.” [Carer]

And here is CRASH’s subsequent response:

ngngGH to SH - Complaints Policy 001 V2

Having outlined Southern Health’s continuing failure to listen, respond and improve, it appears that this is being orchestrated by the ‘old guard’ amongst Trust officials, who are innately resistant to change. 

Myanma_A_16975_2 v1

 

CRASH remains hopeful that the new Board of Directors will separate the wheat from the chaff.’

©

©Hear Women Talk

 

State of Play

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.

 

We welcome the appointment of Lynne Hunt as substantive Chairman of Southern Health, effective 3 July 2017.

 

Most recently, Lynne was Non-Executive Director and Vice Chair of Dorset Healthcare NHS Foundation Trust, a Trust that has undergone its own transformation over the last four years.  Lynne’s empathy, humanity and belief in customer inclusion impressed Governors and members of the public present at the Extraordinary Meeting of the Council of Governors (“CoG”) on 5 July.

The CoG approved the appointment of three Non-Executive Directors with impressive backgrounds, completing a clear-out of the ‘old-guard.’ Note to self: update ‘About‘ page (now completely out of date) and add to ‘Seven up and counting‘ (now up to 10!).

With the appointment of an entirely new Board of Directors, it is evident that Interim Chairman, Alan Yates has established solid foundations for reform at Southern Health. Alan is described by a long-standing critic of Southern Health as:

A new and much more business-like Interim Chairman … started to talk seriously to the families and to current and past governors to find some solutions to the Trust’s problems.

One of Lynne’s priorities now is to translate these solid foundations into real progress: action that demonstrates clearly and unequivocally to the public that the culture of the Trust and its attitude to patient safety is improving.  In a Position Statement read to the Board Meeting on 27 June, John Green, former Governor of Southern Health said:

“It would seem that there is still a substantial disconnect between some of the executive directors, senior managers and consultants of this Trust and the NHS top hierarchy and customers, reflected by the fact that they continue to carry on in the same old isolated way. Unlike the approach by Alan Yates…, many continue to treat customer complainants as an enemy … and people to be ignored and avoided.

“Personally, I believe that, without the full involvement of family carers, high
quality standards of mental health and learning disability services are not possible. In other words, this Trust should see them as a valuable resource. It cannot achieve the transformational change needed without them.”

Download John’s statement (as amended) here→ Position Statement – 27.06.2017. And so say all of us! This is the challenge facing Lynne.

These events coincided with publication ofThe Busy, the Bossy & the Bully‘, a searing exposé of bullying in the NHS; the inability of NHS mental health Trusts to support staff members; and the impotence of the Nursing & Midwifery Council (“NMC”).

41eO1NZQ07L._SX351_BO1,204,203,200_

 

Incorporating The NHS, the Uniform & the Blackberry®‘, this is the true story of James, a mental health trainer, a victim of bullying and mobbing, driven to attempt suicide.

The second part of the book, ‘Justice is a Long Road‘ tells the rest of his story. It shows how NHS Trusts use their muscle to fend off complaints and it shines a bright light on the ineffectiveness of NMC.

© Lucy la Zouche 2017

 

It appears that NHS staff are treated the same way as service users and families, who complain and that its disciplinary procedures are not dissimilar to Southern Health’s complaints process – that is, akin to a Kangaroo Court.

CRASH believes that this book is essential learning material for all Southern Health executives and staff. 

47997813 - woman doctor isolated on white

 

Council of Governors

25 July 2017 – 14.00hrs.

Holiday Inn, Telegraph Way
Morn Hill, Winchester, SO21 1HZ
Get directions→

 

The Scales of Justice?

26056190 - scales of justice isolated on white vector illustrationThe rule against bias is one thing. The right to be heard is another. Those two rules are the essential characteristics of what is often called natural justice [our bold].

“No one who has lost a case will believe he has been fairly treated if the other side has had access to the Judge without his knowing.”

Lord Denning¹

 

The Privy Council and (in another case²) the House of Lords established that the law of natural justice is not restricted to judicial decisions: it applies also to quasi- and non-judicial decisions, which are of a judicial nature.

We believe the law of natural justice applies to NHS complaints processes too. Indeed, notwithstanding this, complainants have a right to a fair hearing under Article 6 of The European Convention on Human Rights.

Department of Health guidance to NHS complaints handling effectively confirms this with words such as, fair, open, transparent and unbiased. We provided compelling evidence that Southern Health’s complaints process is akin to a Kangaroo Court, in which the principles of law and justice are disregarded or perverted. Read more here→

At the request of Interim Chair, Alan Yates, CRASH has submitted a review of part of Southern Health’s procedures. Download here: Complaints Investigation Report

CRASH recommends that those making complaints against Southern Health should insist that the process conforms to ‘the law of natural justice.’ It is important to insist on this in agreeing the Terms of Reference (“TOR”) before an investigation commences: it requires patience, persistence and robustness – one recent complainant reached Version 10 of the TOR before Southern Health even came close to agreeing a fair and transparent process. 

A Common Sense Approach to Information Sharing

Another essential element of a fair process is ‘equal access to evidence’; sometimes referred to asequality of arms.‘ Again complainants must be persistent and robust in ensuring that the patients’ data are complete and accurate.  

Locked file 2

CRASH often hears stories of Southern Health withholding, destroying or retrospectively amending key papers to make it difficult for Coroners, Regulators and complainants. 

 

 

On 28 April 2017, Southern Health’s Interim Head of Patient Engagement and Experience announced a workshop allegedly to involve current service users, families, carers, and staff in developing understanding and information in respect of confidentiality and information sharing.

“We are doing this because feedback from all groups indicates there is frustration and confusion about what can and cannot be shared…. We want to improve that situation.”

CRASH was unable to attend but submitted a paper on the subject. Southern Health did not even disseminate it to its own officials, who were facilitating the workshop, much less the delegates!SH - Slide 002

Even more alarming, subsequently we learnt that Southern Health actually misinformed bereaved families and others about The Access to Health Records Act 1990. Opposite is a slide used at the workshop→

 

The Access to Health Records Act 1990 does not state that access is permissible if, “The applicant has a claim arising from the death.” Section 3(1)(f) of the Act states specifically:

“Any person who may have a claim arising out of the patient’s death [bold added].”

The Trust’s omission of, “May” perverts the meaning of the Act significantly. It is evident that many bereaved families may have a claim but they will not know if they have a claim without sight of the records. Also, Southern Health’s definition of the deceased person’s representative is far too restricted in this context.

The feedback received from the delegates at the workshop is almost universally negative.

“The tone of the slides was reflected both by how the presentation was delivered and also by the SHFT leaflet that was put out ahead of the meeting.

“The two leaflets, one from SHFT and the other by NTW [Northumberland Tyne & Wear NHS Foundation Trust]…, could not be more different. The SHFT one addresses the patient and is a very dictatorial this is what information we hold about you and why. This is what we can and will do with it. In contrast the NTW leaflet is written for the carer/family, recognises their important role in the Triangle of Care, and how this benefits the patient. It addresses the issue of what will be done to share as much relevant data with the carer as possible in order to strengthen this approach and make it more beneficial for the patient.

“There are too many [name] in the Trust that drag it down. Let’s hope the new Chair and new CEO have the strength of character to see this and weed them out.

And one positive:

“By contrast there were a couple of younger members of staff present at the meeting who did impress me. They see the future different to the likes of [redacted]. They buy in to the way we see it. Let’s hope that with the change in Executive these people are identified and nurtured so they float to the top.”

CRASH does not know the names of the “Young members of staff”.

Once again, Southern Health engaged in a process intended to show that the culture is improving but achieved exactly the opposite by distorting and/or omitting facts. In particular, misquoting an Act of Parliament is unforgiveable.

As a result, CRASH submitted a revised paper to the Interim Head of Patient Engagement and Experience containing the original content and two further pages added as a result of feedback. Download here: A Common-sense Approach to Information Sharing

We asked how Southern Health would remedy the misinformation. This is the response:

“Thank you for the papers you prepared on Information / data sharing, which will have taken you some time to research and write. I appreciate the time and trouble you have gone to, to provide us with this important information.”

Conveniently overlooking that they didn’t use it!!

Mr Angry 2Just to ‘stick the knife in’, when we asked Southern Health to remedy the errors above, we were criticised for causing too much work for officials – conveniently overlooking that they caused the extra work by disseminating erroneous information in the first place.

An interesting variation of mother blame‘.

 

To38327771 - dissatisfied survey with red circle and pencil on textured paper paraphrase Lord Denning:

No one who has had a complaint rejected by Southern Health will believe they have been fairly treated if Trust staff and officials have had sight of a draft report and an opportunity to challenge it without the same opportunity to view and challenge it.

 

14716858 - scale favoring self interest rather than personal values¹Kanda v Government of the Federation of Malaya [1962] PC 2 Apr

² Ridge (A.P.) v Baldwin & others [1963] UKHL 2

Kangaroo Court

14528651 - illustration of a kangaroo in cage and wooden board

Definition:

A mock court in which the principles of law and justice are disregarded or perverted. In such cases, one party has already been deemed guilty/innocent and the other has little or no opportunity to question the verdict. 

 

On a recent inspection, Care Quality Commission Inspectors allegedly concluded that Southern Health’s Complaints Procedures have improved. This is a great mystery as its Complaints, Concerns and Compliments Procedure is unchanged since August 2016.

Appendix 10 of the Procedure (ACTION CARD for the Investigator) is revealing . Brief extracts from the, “Suggested methodology for investigating the complaint” [abbreviated]:

  • Follow the terms of reference….
  • When you have spoken to or met the complainant….
  • Order the critical records….
  • Review any policies, local procedures and national guidance.

There is no reference to the complainant agreeing the Terms of Reference or having an opportunity to check the ‘critical records’ for completeness and accuracy. 

Then, after several more stages involving staff, experts etc., the investigator draws conclusions without any further involvement of the complainant, until finally:

  • Make sure any staff involved have sight of your investigation [report] and final response letter and an opportunity to comment on these.
  • Obtain sign off/authorisation from the commissioning manager prior to submitting your investigation and response to the Customer Experience Advisor.
  • The final response is signed by the Chief Executive.

Read Appendix 10 in full here→

The ‘Action Card’ bears no resemblance to official guidance¹. A fair process allows complainants to be involved at every stage, in particular, towards the end:

“Once you [the investigator] have all the evidence, you can review it to identify all points of agreement and disagreement. It can be useful to summarise these for everyone concerned [bold added].

“It can be very helpful to the process and constructive to issue a statement of agreement early on. This lets all parties know that there is a basis of agreement to build on. This then allows all attention and resources to be focused on the areas of outstanding disagreement [bold added].

“The investigator normally works through all the points of contention until they have reached a considered view on every aspect of the complaint.”

And as final step, the official guidance¹ makes clear [emphasis added]:

“Give both parties the chance to give feedback.

Before the report is finalised, everyone involved should have the chance to give you their views on what you have said. It is important to correct any factual inaccuracies before publication.

If you change the report in any major way, remember to let all the parties know and give them a chance to comment before the final report is issued.”

The Care Quality Commission cannot claim that Southern Health has improved its complaints process recently. In a meeting last month with two long-standing critics of the Trust, the Interim CEO confirmed that complainants would not, in all cases, see a draft investigation report or final letter or be given an opportunity to comment on them.

Why has the Care Quality Commission not compared Southern Health’s procedures with the official guidance¹, details of which are below with links to the full documents? 

In short, Southern Health’s complaints process is that of a Kangaroo Court.

13931038 - kangaroo border around white copy space

¹THE RIGHT WAY

Southern Health has no defence for biased procedures. The Department of Health wrote to all NHS CEOs introducing guidance issued pursuant to The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009. It was effective from 1st April 2009.

It established a single approach to dealing with complaints and encouraged a culture to seek and use people’s experiences to make services more effective, personal and safe. 

The guides ‘Listening, Responding, Improving’ and ‘The Quick Guide to Customer Carehelped complaints professionals work with colleagues to make their organisations better at listening, responding and learning from people’s experiences. Additional advice sheets for complaints professionals were also produced covering: investigating complaints, joint complaints that involve more than one organisation and dealing with serious complaints that have safety implications. 

The ultimate irony is that, in ‘Listening, Responding, Improving’, Gemma Seymour, Consumer Experience Development Manager for Hampshire Partnership Trust (which morphed into Southern Health with Gemma in a similar position) writes inter alia:

“You need to listen and let them tell their own story, in their own time. Doing this helps me to establish the facts, which I always check with the complainant to ensure they are correct. I try to make things as easy as possible.

“People also appreciate being given as much of a say as possible. If someone wants their concerns investigated, we involve them in putting together the plan of action.

“The fundamental point is that when you listen, involve and engage people, it makes it much easier to sort out the problem to everyone’s satisfaction.”

42603567 - a cartoon illustration of a sinister looking little kangaroo.

So Gemma contributed to ‘Listening, Responding, Improving’ but then ignored it – or Southern Health (Katrina Percy) prevented her from implementing it. 

 

 

One has to ask, if Southern Health had adopted a fair and transparent complaints process on its formation (2011) rather than turn a blind eye to official guidance,  would its services have been more effective and safe?

 

Epilepsy Rage 2

4559220 - short sighted man needs binoculars to read his book

Director reading Strategic Risk Assessment

 

On 29 April 2017, we identified five ‘learning opportunities’ in epilepsy, from which Southern Health failed to learn. The ‘learning’ continues … or does it?

First, a simple eye test. Body text in Strategic Risk Assessments is CIDFont+F1, size 4.

 

 

SIZE MATTERS

Having spent so much time reading Southern Health’s ‘mouse print’ – see previous post –  your scribe decided it was time to visit his optician.  Now try this test:

Font Size4

This image is CIDFont+F1, sizes: 4 to 14 in 2pt steps. Which can you read comfortably?

 

Optician astonished that NHS is producing important documents in font size 4. There is no statutory limit but guidelines indicate that print should be legible to someone with normal eyesight, or with glasses, which correct to normal. 4 is the lowest possible limit.

In short, a good, comfortable font size is necessary for readable text. This rule is old news but clearly not for Southern Health – unless they don’t want people to read it.

LEARNING OPPORTUNITY 6

Following the Care Quality Commission’s decision on 6 March 2017 to prosecute Southern Health for an incident in December 2015, the BBC has reported the Health and Safety Executive’s decision to prosecute the Trust under Section 3 of the Health and Safety Act in relation to the ‘preventable death‘ of Connor Sparrowhawk. Read more here and here. A ‘bitter-sweet moment‘, one might think, for his mother Dr Sara Ryan – who has fought for justice for four years with formidable dedication and energy. 

11763603 - what can i do? picture about regret

What can I do? I’m just a Director?

Or it might have been a learning opportunity if Southern Health had not responded with its usual crass comments and non-apology.

The ‘apology’ was part of a statement Southern Health was sending to journalists!

 

 

They didn’t get in touch with Connor’s family to say sorry. They got in touch with the press. A purely bitter moment. Read more on Sara’s distressing blog→

LEARNING OPPORTUNITY 7

It was alleged at an Inquest into the death of Sasha Taylor (a known epileptic) that a Consultant Psychiatrist had increased the dosage of Olanzapine, an antipsychotic drug, during a telephone conversation to higher than the recommended maximum guidelines. Amongst the side-effects of Olanzapine are seizures – with a specific recommendation:

“Tell your doctor or pharmacist if you have any medical conditions, especially … if you have a history of seizures.”

It makes clear also that there are a number of other drugs that, if used in conjunction with Olanzapine, will increase the risk of side-effects. It is alleged that Sasha was also taking Amisulpride, which has a precautionary warning on epilepsy too, and anti-depressants, which are known to lower the threshold for seizures.

The Consultant said he wanted to lower Sasha’s medication but, in order to do this, he had to briefly raise the level of Olanzapine! We bow to his professional expertise but this offends common sense.

Senior Coroner Grahame Short recorded a verdict of a drugs-related death and said:

“It is worrying for us to learn that these high levels of anti-psychotic drugs, which can have serious side effects, were not monitored over 12 months.”

Naturally, Southern Health responded with the usual platitudes. Clinical Director, Professor David Kingdon said:

“We have carried out our own internal investigation and made a number of improvements to the way we support people on higher doses of medication.

“For example, all our teams now have a nominated physical health lead to monitor the physiological effects of psychiatric mediation, and a review of patients receiving high-dose therapy now takes place at every clinical team meeting.”

Oh really, Professor Kingdon! After dishing out a mountain of drugs (often justifiably) for treating psychosis, schizophrenia, depression etc., many of which have very serious side-effects, Southern Health still didn’t monitor patients’ physical health properly four years after its formation … and the percentage of trained staff is unknown to this day.

15413127 - angry doctor holding telephone

And this is not the first ‘distance diagnosis’ – on 8 March 2017 Coroner Grahame Short heard of an outpatient talking of suicidal feelings but being told by phone just to take a diazepam and have a cup of tea – shortly before falling to her death: read more→.

 

And in 2013, Dr  ‘Mystic Meg Lesley’ Stevens, then Clinical Director, Mental Health Division, used psychic powers to diagnose a patient she had never met or spoken too – even by phone.

And now? We will not use images of barely readable text again but the Trust’s Strategic Risk Assessments for physical health training for November 2016 and April 2017 show:

“New Physical Training programme available for all staff: Attendance % not reported. Course content and attendance recording being reviewed.

“Board Reporting: Attendance accurately not reported.”

Back to School

SUMMARY – STILL NO LEARNING.

And who was successively Clinical Director, Mental Health & Learning Disability Director and Medical Director during this time – Dr Lesley Stevens when will she join the seven

 

Epilepsy Rage

50027334 - learn and lead business concept

 

How many ‘learning opportunities’ in epilepsy does Southern Health need?

 

 

LEARNING OPPORTUNITY 1

The first known incident relating to epileptic-type seizures was in September 2011. A Southern Health Consultant Psychiatrist misdiagnosed the after-effects of a seizure as mental illness and sectioned CRASH, carting him off to a remote psychiatric unit – without advising the unit of the very recent seizure or a suspected TIA.

CRASH was forcibly restrained by two police officers, who were not made aware of his physical illness. A senior officer offered to give evidence to Southern Health’s ‘independent’ investigator but the Trust withheld his offer from the investigator and ‘accidently’ lost a body-map of CRASH’s injuries, which the police had requested.

Four day’s later, a junior Southern Health doctor recorded in CRASH’s notes:

“I did not see any documentation from [A & E] and therefore contacted them. They have faxed across his notes from the ED which state: They have referred [CRASH] to the First Seizure Clinic for a possible grand mal seizure – 1st. Unfortunately, it does not seem that they have performed a CT brain.”

So a patient, at risk of another seizure and/or a TIA, was in Southern Health’s ‘care’ for four days (despite not being mentally ill) and its staff were oblivious to the conditions and thus the risks. Dr Lesley ‘Slippery’ Stevens knew about this in December 2012 (if not before) as Adjudicator of CRASH’S complaint.

Dr Stevens also believes it is lawful to detain patients, who are not mentally ill, under The Mental Health Act, despite that detention without lawful justification has been a tort of strict liability (in which the defence of ‘reasonable care’ is not available) since the Magna Carta. The fight for justice goes on 5.5 years later. 

LEARNING OPPORTUNITY 2

On 4 July 2013 Connor Sparrowhawk, a young lad commonly known as Laughing Boy (“LB”), passed away. A known epileptic, Southern Health staff allowed LB to have an unsupervised bath … the rest is entirely predictable even by non-medics. Read more here→.

Here is an answer to a question at the Inquest by Dr Stevens (from twitter-feed):

Twitter

Key here is not the date of the Inquest per se but that Dr Stevens knew of the need to ‘up-skill’ (train in normal language) staff in relation to epilepsy in 2013 after LB died.

LEARNING OPPORTUNITY 3 

In February 2014, in its first report on LB’s death, independent investigator, Verita recommended inter alia:

  • The trust should undertake a review of the epilepsy care it provides to ensure it complies with local and national guidance.
  • The trust should ensure that trust staff working with patients with a history of epilepsy have access to appropriate advice and support from epilepsy specialists.
  • The trust should ensure that all relevant staff are competent to manage an epileptic seizure.

Verita also made reference to shortcomings in, “Resuscitation skills following incidents requiring CPR.¹” In response to the report, Katrina ‘Teflon’ Percy commented inter alia:

“We have reviewed the training our staff receive in relation to writing care plans and developing risk assessments for patients with epilepsy. All staff across the Learning Disabilities Division will undergo enhanced training and this will be mandatory. “

Read more of her duck-billed platitudes here→

LEARNING OPPORTUNITY 4

Three months’ later in May 2014, 18-year old teenager Edward Hartley died following complications from an epileptic seizure. Allegedly, Southern Health has not formally acknowledged that Edward’s carer had not been epilepsy-trained. His family believe he hadn’t but have no proof. However, the Trust acknowledged that the career hadn’t received BLS² training, so it is unlikely he was epilepsy-trained too.

Astonishingly, three years later his parents say they are no closer to finding out the truth.  We are constrained about what we can say by a second investigation report, which has not yet been issued.  Read more→

LEARNING OPPORTUNITY 5

Following Connor Sparrowhawk’s Inquest, on 2 November 2015, the Oxfordshire Coroner issued a Regulation 28 Report – Prevention of Future Deaths to Southern Health raising serious concerns relating to epilepsy care and recording.

The response to the Regulation 28 Report by Katrina ‘Teflon’ Percy is full of more duck-billed platitudes and re-assurances, including details of how staff would be informed of required improvements in relation to epilepsy.

Download the full Regulation 28 Report and Southern Health’s response on the web site of the Judiciary for England and Wales here→.

OUTCOMES BY 22 NOVEMBER 2016

So, even 11 month’s after Katrina Percy’s undertaking to the Coroner, are all relevant staff trained and competent in epilepsy? The answer is in November’s Board Papers.

Extracts from Agenda Item 10 – Board Assurance Framework dated 22 November 2016: pdf file page number 162.risk 3a

risk4a

Southern Health itself doesn’t actually know what percentage of relevant staff have attended training or are competent in epilepsy. It hasn’t even allocated an ‘Assurance Group’. ‘Action’ is required but they have not even allocated an ‘Action Owner’

OUTCOMES BY 19 APRIL 2017

And the April Board Papers reveal that the only progress made in five months (16 months after Katrina Percy’s letter to the Coroner) is the allocation of a ‘Risk Owner’ – Bobby Moth³ – obvious one might think: she is Associate Director of the Leadership Education and Development Team and co-author of a paper, ‘Nurse Revalidation‘.

Indeed, in that role, why is she not be keeping figures for her own information anyway?

Extracts from Agenda Item 10 – Board Assurance Framework dated 25 April 2017: pdf file page numberRisk April 2017 1 001b 266.


Risk 2aAnd look at the slight of hand – whilst risk scores are unchanged from November, the assurance strength appears to have improved from “weak” to “partial assurance” even though, on epilepsy (and other) risks, there appears to be no assurance at all!

SUMMARY OF ‘LEARNING’

In short, despite all these ‘learning opportunities’, over five years after the first known incident; three years after the CEO promised to ensure trust staff were trained and competent in managing epileptic seizures; and over 16 month’s after the CEO’s letter to the Coroner, its Medical Director, Dr Lesley Stevens cannot tell the Board, patients, families what percentage of relevant staff are trained and have competency in epilepsy. Perhaps she uses her mystic powers.

OTHER OBSERVATIONS FROM THE STRATEGIC RISK REPORTS

  • Two of the major public health concerns currently are dementia and diabetes. The training and competency records on these are no better than those for epilepsy.
  • Not all staff hold signed competencies in their personal portfolios.
  • Clinical Supervision Policy – records of compliance are not 100% and some teams are not formally recording supervision.

 

10567257 - high voltage sign

AND MOST SHOCKING OF ALL?

Despite two Board and Council of Governors Meetings and Care Quality Commission inspections, not a single Director, Governor or CQC Inspector has challenged these failures. 

 

CRASH makes no apologies for the ‘mouse print’ – it is how the Trust publishes its reports, probably to disguise its failings. Lucy la Zouche commented:

As for the Risk Analysis – they always seem to have documents like this in the smallest possible print and with a three-way risk assessment in full colour, But, they still consistently screw things up. Perhaps they need to get some good managers and get rid of some of the analysts, strategists and other hangers on.” 

Even using the original Board Papers, it is necessary to use the pdf zoom facility! Read all the pages in both (total 697) and recall the adage – excreta tauri cerebrum vincit.

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

 

Misleading – learning apparently never starts for Dr Stevens and Bobby Moth.

And what does this say about their leadership?

 

¹ CPR – Cardiopulmonary Resuscitation        ² BLS – Basic Life Support

³Moths: Quite frightening as they tend to appear at dusk!

Learning opportunities

Lucy Cartoon

Contrary to this platitude, used by the NHS to disguise a cock-up, this is a real learning opportunity.

Three of these books were used for public questions at the last Southern Health Board Meeting and many Trust Directors expressed an interest in obtaining them.¹

They are essential reading for Southern Health service users, complainants and staff too. The two by Lucy la Zouche are of special relevance: readers can work out why for themselves.

 

The NHS, the Uniform & the Blackberry® ²

Lucy 1 002

 

A gripping, true story about bullying in the NHS. The subject of the book, a Mental Health Nurse Trainer, got into a downward spiral of Reactive Depression after being subjected to extreme Workplace Stress. His management, some of them qualified Mental Health clinicians, ignored his symptoms and treated him as a delinquent.

Copyright: Lucy la Zouche 2013

 

 

Lucy likens the disciplinary process to a Kangaroo Court:

“A mock court in which the principles of law and justice are disregarded or perverted.”

Complainants could apply the same description to Southern Health’s complaints process.

NMC Survival Guide (2nd Edition) ²

Lucy 2 002

 

The aim of this book is to provide a guide, which will demystify a protracted and stressful process and, help nurses and midwives get the best possible results. This 2nd Edition includes all the legislative and associated changes up to November 2015. For the rest of us, it is an interesting guide to how one health regulator operates.

Copyright: Lucy la Zouche 2014 & 2015

 

 

Medical Ethics and Law (2nd Edition)

Ethics 003

 

This academic tome provides an up-to-date, clear and accessible account of medical ethics and law. It will assist some Southern Health complainants too, for example ethical issues and law relating to detention under the Mental Health Act 1983 and reporting mentally ill patients to the police.

Copyright: Elsevier Limited 2003 & 2008.

 

 

Ironically, this tome was recommended by the excellent Dr Mayura Deshpande, Chair of Southern Health’s Clinical Ethics Committee.

Southern Health should not (but already have and probably will continue to) disagree with views expressed in a textbook recommended by the Chair of its own Clinical Ethics Committee – but at least complainants will be fully prepared!

The Indian Lunacy Act, 1912: The historic background

Lunacy Act 2 003

This 1987 paper on the Indian Lunacy Act 1912, enacted under the rule of the British Crown, includes a section: ‘The British Background’. (Free access)

 

This section is a useful summary of the history of mental health legislation in Britain extending back 172 years and supports an inconsistency between The Mental Health Act 1983 and Article 5 of the European Convention on Human Rights. More to follow.

As a point of interest, it is astonishing to note that the word, ‘Lunacy’ was not replaced in Indian Law until The Mental Health Bill 1986. Even Southern Health’s service users should be grateful for that.

For another relevant book, click here.

FOOTNOTES:

¹ CRASH has access to sales trends on Lucy’s two books: it will be interesting to see if there is a spike after the Board Meeting.

² The books by Lucy la Zouche are available through the links provided – or Amazon

Seven-up & counting

13172924 - emoticon clapping

15 months (almost to the day) after publication  of the Mazars Review, Non-Executive Directors finally find their consciences!  Or was it their appraisals, which encouraged them?

Nice one Alan.

 

 

Chairman of Audit Sub-Committee, who failed to act when the overspend on the Talent Works contract was identified. Also Chairman of the Rural Payments Agency, which the National Audit Office seriously criticised inter alia for, “Poor and dysfunctional leadership and wasting public money:

Claimed never to have been part of a corrupt organisation. Read more→

 

Judith Smyth for website X

J Smythe

 

Claims to be expert in commissioning, governance and strategic leadership with a style: “Challenging, upbeat and strongly focused on outcomes.”

So why did Mazars expose a 4-year failure of leadership and governance and why was Katrina Percy’s conduct not challenged robustly.

 

 

Alleged experienced health and social care leader; clinician (Mental Health, Older People Care and Learning Disabilities); experience of service improvement, organisational change and strengthening  governance.

So why did we not see these skills used to improve Southern Health.

 

Tracey Faraday-Drake for website X

T F-Drake

 

Claims to be, “Deeply committed to endeavouring to provide exceptional high quality services for the most vulnerable people in our society.”

Tell that to those who lost loved-ones under Southern Health’s care!

 

 

 

Gained some sympathy in the last few months but too late.

Associated with notorious breach of data security.

 

 

 

And much earlier:

oo7

Nearly sunk a sinking ship.

Just search this blog or the web for details.

 

 

 

20314344 - dog with a bag of cold water on his head

Pass the sick bag – Katrina Percy, Strategy Consultant is coming out to play.

Could this really be the LinkedIn profile of the same person?

 

“An experienced Chief Executive with over 20 years in healthcare leadership across all sections of the NHS and internationally. I have a track record of inspiring individuals, organisations and systems to transform the way they operate and have developed a reputation as a highly regarded Chief Executive, known for:

● Inspirational and visionary leadership, attracting and developing highly talented leaders
● Focusing on staff engagement to improve productivity, innovation and quality
● Creating a culture which is open, accessible and energised, and results in improvements in patient care across a large dispersed organisation
● Delivering ambitious service transformation, financial, quality and operational performance
● Successfully delivering a major acquisition of services.”

Katrina Percy B.Sc. First Class Honours in Irony?

Katrina structure X

 

Katrina Percy

B.Sc. Hons, Geography, Upper Second Class Honours


Justice comes knocking

Disrupted

A week in the life of Southern Wealth Health

22032231 - grumpy old judge in extreme wide angle closeup with hammer and wig

6 March 2017: the CQC informs Southern Health of its decision to prosecute the Trust for a health and safety incident, which took place in December 2015 at Melbury Lodge.

The incident involved a patient getting on the roof and falling from it, injuring himself. Read more→

 

We have obtained a copy of an internal email sent to Southern Health staff by the Trust’s Interim CEO. Amongst the platitudes:

“As you know the safety of the people that use our services is central to everything we do…. The work [subsequent improvements at Melbury Lodge] will not only make the ward safer for patients but it will be a much more therapeutic environment.”

So why the ongoing serious incidents; why, in a hospital for potentially suicidal patients, was access to the roof even possible; and why wasn’t it safe for patients already after a number of earlier ‘wake-up calls’. It went on to say:

“We expect this announcement to attract some media attention over the next few days. Whilst I know this is disappointing, I want to assure you that we are continuing our work to improve our relationships with the media and achieve more balanced coverage.”

Surprise, surprise! Does Southern Health’s overstaffed (and probably overpaid) Department of Spin not realise that the Trust’s relationship with the media will only improve with (amongst other things):

  • A major reduction in the number of serious incidents.
  • Proper accountability for previous serious incidents.
  • Major ‘surgery’ to the Board of Directors and Council of Governors.
  • Openness and transparency.

18489902 - silvery diplomat (suitcase) isolated on white

8 March 2017: Winchester Coroner’s Court.

Inquest into the death of Jackie O’Neill.

Alarming similarities to the death of Marion Munns: no robust care plan in place and no response to crisis call just before 5pm.

 

 

On this occasion, the deceased herself had called the crisis team talking of suicidal feelings but was told just to take a diazepam and have a cup of tea. Later, she called 999 and two paramedics attended: they took great care in calming her but even they could not contact the crisis team. She fell to her death shortly thereafter.

Unbelievably, Southern Health’s ‘witness’ was a hapless Consultant Psychiatrist, who had never even met Jackie, armed only with a copy of an internal investigation report – we all know what these are like – but even that was redacted. So when the Coroner or family members asked legitimate questions (especially names of Southern Health personnel)  he could legitimately answer that he didn’t know. And the Coroner didn’t even challenge it.

Clearly family members, many of whom had travelled a long distance,  were distraught at not learning the names of those responsible for the ‘care’ of their loved-ones. So much for SH improving the treatment of bereaved families: SH showed contempt for the family and, in our opinion, for the Court. 

The Coroner concluded that there was not an adequately robust care plan in place but despite this (and the unavailability of the Crisis Team),  he did not offer to write a Regulation 28 ‘Prevention of Future Death’ Report.  This is not without irony: Irwin Mitchell, solicitors acting for the family at the Marion Munns Inquest, confirm:

“The Coroner stopped short of writing a regulation 28 letter demanding improvements saying it is clear that care and delivery issues have had a profound effect on the team and Trust and that this incident had become a wake-up call to them with steps being taken to address shortcomings.”

alarms-with-writingThe Coroner at both Inquests? Graeme Short.

Two deaths with the same shortcomings – and still no regulation 28 report. So Mr Short, how many wake up calls does Southern Health need?

 

9 March 2017:

By coincidence, the reopening of Melbury Lodge and two classic goofs:

Goofy 2

1. Having said three days earlier that they wish to improve relationships with the media, Southern Health gives exclusivity to ITV Meridian, ignoring the BBC and print media!

2. Director, referring the ‘hapless’ Consultant and the lack of other staff at the Jackie O’Neill Inquest: “He was happy about it.” So, that’s alright then: don’t worry about justice or the family.

And a bevy of Spin Doctors to take care of one media organisation and a few guests.