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

– AND NOTHING ABOUT SOUTHERN HEALTH!

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Triangle of Care

The combined hands, are forming a triangle

The Triangle of Care 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.”¹

 

 

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.”¹

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. 

¹’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?

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.

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.

cd-496

 

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!

MENCAP

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!

FOOTNOTES: 

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

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.

WALKING WITH ALPACAS

KONICA MINOLTA DIGITAL CAMERA

 

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 postmaster@hampshire.pnn.police.uk 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.    

Equality – the Indian Way

Panoramic view of Taj Mahal at sunset

India beat England – and not just at cricket.

On 12 April 2017, we referred to The Indian Lunacy Act 1912 and a paper, summarising the history of mental health legislation in Britain extending back 172 years. We noted the word, ‘Lunacy’ was not replaced in Indian Law until The Mental Health Bill 1986.

Now, in the field (pun unintended) of mental health, leading academics¹, write of the new Indian Mental Healthcare Act 2017  (“IMHA):

“In theory, the IMHA is a highly progressive piece of legislation, especially when compared to legislation in other jurisdictions subject to similar analysis.

“Overall, it is likely that India’s new mental health legislation will impact on more individuals than any other piece of mental health legislation in the world”

They found India’s compliance with the World Health Organisation’s ‘Resource Book on Mental Health, Human Rights & Legislation’ (“WHO-RB”) standards generally good and more compliant with these standards than legislation of Eire or England & Wales. 

In particular, they claim that the UK Mental Health Act inadequately addresses the fundamental rights of voluntary patients, vulnerable patient groups, emergency treatments and economic and social rights.

So let’s look at some important sections of the IMHA [paraphrased] in comparison with UK legislation:

S.18(1) and (2): Every person has the right to access mental health care treatment and services run or funded by Government which are affordable, of good quality, in sufficient quantity, available nearby, and without any discrimination.”

Are our mental health services of sufficient quality and quantity and always available locally? Clearly not. 

S.19(1): A patient with mental illness (“PMI”) has the right to live in the community and be part of and not segregated from society.”

Are UK Community Mental Health Teams (including Crisis Teams) adequate for this to be a realistic objective? Clearly not.

S.20(2): PMIs shall be protected from cruel, inhuman or degrading treatment and have the right to live in a safe and hygienic living environment, proper sanitation and facilities for leisure, recreation, education, religious practices and privacy.”

In the UK, the availability of a safe environment and adequate facilities, free from inhuman and degrading treatment, cannot be guaranteed. See also s.97(1) below. 

S.21(1): Every person with mental illness shall be treated as equal to persons with physical illness in the provision of all healthcare.”

Speaking on 10 October 2013, Norman Lamb MP said it all: 

“There is an institutional bias against mental health within the NHS.” (Read full speech here→.) 

Some politicians do tell the truth!

“S.21(4): Every insurer shall make provision for treatment of mental illness on the same basis as is available for treatment of physical illness.”

If UK insurers had to cover mental illness on the same basis as physical illness, it would relieve the pressure on NHS mental health services considerably.  

S.27(1): PMIs are entitled to receive free legal services to exercise his/her rights available under the Act.”

In UK, non-means tested legal aid is available only whilst a PMI is detained under a section. Otherwise a PMI, who wishes to take legal action, must fund it themselves, even if breaches of mental health legislation have life-changing consequences. 

S.97(1): Seclusion and solitary confinement is totally banned and physical restraint is to be used sparingly, when absolutely needed, and deemed the least restrictive method.”

The young woman, behind barSeclusion and solitary confinement are not unusual in the UK: ask Bethany, 17, who has autism and extreme anxiety; has been locked in a seclusion room for almost two years; and is fed through hatches. Her father had to fight off Walsall Council’s bid for a gagging order stopping him from speaking out about his daughter’s treatment. Read more here→

 

Straight Jacket reduced

 

Physical restraint (including ‘face down’ restraint) has increased in recent years with reports of PMIs being fed through hatches in seclusion, forcibly injected with powerful drugs to sedate them, and violently restrained by up to six adults. Read more here→

 

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

How many Inquests identify lack of adequate care plans as a contributor to suicide when PMIs are discharged? How many PMIs and families complain about lack of consultation before discharge; transfer between units and/or a change in Consultant Psychiatrist? 

Regarding family involvement, it is worth noting that WHO-RB specifies:

“Two occasions exist when the family and carers are automatically involved; these are: when planning discharge and in the case of a person found wandering in the community.”

Incorporating this into the Mental Health Act would put an end to Trusts using data protection legislation as an excuse not to involve the family at key stages. 

S.108: Any person who contravenes any provision of the IMPA (or related rules and regulations) is liable to imprisonment for up to six months or a fine of up to 10,000 rupees [£110³] or both for the first offence and imprisonment for up to two years or a fine of up to five lakh rupees [£5,500³] or both.

We believe it oppressive to incorporate criminal law against individual clinicians in the Mental Health Act. There are sufficient sanctions in UK law (including common law) to cover serious cases, such as manslaughter, false imprisonment and Misconduct in Public Office. Other aspects of professional misconduct are for Regulators to determine. 

The difficulty is that the police are reluctant to investigate medical professionals (save in the most blatant cases, such as Dr Shipman) and UK Regulators are insufficiently robust to hold medical professionals to account. 

“S.109: Where an offence is committed by a company or organisation, every person who, at the time the offence was committed, was in-charge of and responsible to the company as well as the company shall be deemed guilty … and be punished accordingly.”  

At Southern Health (and probably elsewhere) we know the difficulty (some may say impossibility) in holding Trust Directors to account. For this reason, we believe there are benefits of incorporating a clause based on S.109 of the IMHA into the Mental Health Act.

Reservations

Of course, there are common barriers to full implementation of the IMHA, including inter alia funding, staffing, public health priorities and stigma, which cast a shadow on the new legislation. But then, don’t these barriers apply in UK too?

Also, adequate diagnosis of mental illness is essential for high quality mental healthcare, as is the need for high level clinical training and judgement for accurate diagnosis. In UK, it is evident that accurate diagnosis and effectiveness of training is patchy, and revalidation and regulation of psychiatrists is poor.  

But overall, Duffy and Kelly¹ conclude:

India realistic waving flag vector illustration. National countr“Other countries revising their legislation would undoubtedly benefit from studying India’s constructive, pragmatic and enlightened approach to this matter.”

 

 

¹  Richard M. Duffy and Brendan D. Kelly

² International Journal of Mental Health Systems

³ Exchange rates on 26 November 2018 

Car Crash


Car Accident CartoonWith three (possibly four) fatal incidents coming to light, last week was truly a Car Crash for Southern Health. The media reports largely speak for themselves.

Especially disturbing was the Inquest into the tragic death of Ellie Brabant, which commenced on 5 November and ended on 12 November. The Forum for Justice, Accountability and Equality at Southern Health (“the Forum”) was well-represented – five people ensuring that one member was present for part/all of every day.

karl marlowe - Spin DoctorBBC journalist, James Ingham produced a superb report for BBC South Today and presenter, Sally Taylor interviewed the family solicitor. Producer: Ian Lauchlan¹: view full report here→.

Perhaps the most unedifying and (to the family) disrespectful images are the sight of Medical Director, Dr Karl Marlowe, scurrying away with his ‘spin doctor’ hurrying along behind.

Email your views to Dr Marlowe here→

 

There is also a written report here, which summarises the criticisms of Southern Health, which the Coroner will write in his Prevention of Future Deaths Report [“PFD”].

In addition, the Coroner will write separately to the Trust re: disclosure and preservation of evidence after a serious incident. Yes – the Trust was caught withholding key document (where have we heard this before?) and failing to secure the scene.

Unusually, Sarah Hemingway,  Counsel for Ellie’s family, who met members of the Forum present at the Inquest, wrote to CRASH:

“Thank you very much for your email below and your input during the course of the inquest…. I wish you and the families’ campaign group all the very best in holding SHFT to account.”

Sarah and her instructing solicitor, Alice Stevens, did sterling work in exposing Southern Health’s failings, making a compelling (and successful) case for a PFD.

We know less about the other three cases but press reports largely speak for themselves:

Martin Pope: Mr Moth’s family and friends had concerns about support from Southern Health in the weeks before his death with an apparent breakdown in communications. Assistant coroner Simon Burge said:

“As a result of the breakdown (in communication) there was a failure to appreciate how desperate Paul was.”

Sheriden Harris: We quote Fareham MP, Suella Braverman:

‘This is a tragic loss of life, we must think of Sheriden’s family and friends at this time.

‘It highlights the need for serious and meaningful change to ensure more patients are not failed, and to protect the most vulnerable.’

Southern Heath said it has learned from mistakes in caring for a woman with learning difficulties: they said they have worked hard on addressing failings identified by the report, following the Sheridan’s death in May 2017.

Where have we heard this before? Oh yes! Connor Sparrowhawk and Edward Hartley, young adults with learning difficulties, who passed away respectively in July 2013 and May 2014.

Connor’s family finally got justice on 26 March 2018, when Southern Health was fined £1,050,000 (excluding costs) for an offence under The Health and Safety at Work etc. Act 1974. Read more here→and Mr Justice Stuart-Smith’s sentencing remarks (on this and another case) here→.

Edward’s family are still waiting for justice even to this day.

Baby Stanley: WARNING: some might find this case distressing.

We  cannot prejudice a continuing trial in Winchester Crown Court and, at this stage, Southern Health’s involvement (if any) is unclear too. There is simple reference in the BBC’s report to a Health Visitor: Fareham & Gosport Clinical Commissioning Group inform us that Southern Health employees Health Visitors in its area.

FOOTNOTE:

¹ Ian Lauchlanalso an, “Obsessive Quins rugby fan.”

Bedlam,’barbaric’ secure hospitals

Quote

via Bedlam¹,’barbaric’ secure hospitals, #rightfullives

37765453 - the bethlam royal hospital also known as bedlam

“At least 40 people with a profound learning disability or autism have died while admitted to “barbaric” secure hospitals the government has promised to close since 2015, a Sky News investigation has found.” Read full story here→

Most alarmingly, the number of cases of restraint in England rose from 16,660 in 2016 to 28,880 last year, a rise of 73%. NHS England alleges that the increase is explained by better reporting of incidents. [Oh really?] If we believe that, 12,220 cases of restraint went unrecorded in 2016 – 235 per week. Who’s being held to account for that?  

And the allegation that health services in Scotland, Wales and Northern Ireland were unable to provide figures is simply scary.

Sir Stephen Bubb² said that government’s failure to act was putting patients’ lives at risk:

“There are deaths of people in these institutions, some of them unexplained. We know there are significant problems and there will be at some stage another scandal, and yet we know what we need to do.

“The idea that in the 21st century you lock people up, you restrain them, you use prone restraint, you hold them down, I think is disgusting, it is barbaric and it is unacceptable, and it needs to be made unlawful.”

ignorance Plato

 

Adapting the words of Greek philosopher, Plato, in the context of mental health & LD:

IGNORANCE, THE ROOT & STEM OF ALL DANGER! 

 

¹ People with illnesses, which we now recognize as schizophrenia, depression, autism, and epilepsy, might all have found themselves in Bedlam.

² Sir Stephen Budd led the work, commissioned by NHS England, to support and enhance existing activity, to ensure thousands of people with a learning disability, who are still stuck in Assessment and Treatment Units, are supported to move back to their local community. The press release about the work with links to the full report is here→

Our strategy is to wear them down!

BCC4In advice to it’s staff, Southern Health publicises that Gloucester Police have been fined £80,000¹ for disclosing 56 names and email addresses by failing to use the BCC facility! The police realised their error two days later and recalled the emails.

The words, POT, KETTLE, BLACK come to mind. Southern Health made the same mistake in September 2017. At a Board Meeting on 26.09.17, a member of the public stated:

Bcc Q & A 4

To avoid breaching the addressees’ privacy again, CRASH will not be publishing the errant email – just the Trust’s answer – also from the Board Meeting Minutes:
BCCs Trust Answer 002

In short, no answer at all. Kicked into the long-grass: to the best of our knowledge and belief, the ‘offending’ email was not recalled.

And note that the full public statement is ‘sanitised’ in the body of the Minutes as, Issues relating to data security, whilst the full statement is posted separately from the Minutes on Southern Health’s web site as an Appendix here→. How many just read the Minutes and then look for separate document? There is no logical reason why the Minutes and Appendices should not be in one document.

CRASH, Dr Sara Ryan and others have considerable experience of Southern Health’s compliance (or lack of it) with information governance legislation over the years. The Trust clearly has been reading Dilbert.com.Dilbert

Dilbert by Scott Adams © 2018, Andrews McMeel Syndication

Recently, there has been another very serious breach of data protection legislation, which cannot be reported for legal reasons.

In Memoriam – ‘Vital Interests‘ Exemption

Despite Southern Health’s record on data security , when they can disclose data legally in the ‘vital interests’ of a patient (Sch. 3(3) of The Data Protection Act 1998¹), they don’t.

KONICA MINOLTA DIGITAL CAMERA

 

Wherever we go, it’s hard to avoid Southern Health. This sad epitaph is at Hythe Marina overlooking Southampton Water. 

A 20-year old lad told a therapist at Antelope House that he intended to end his life.

They told the family he had made an appointment, but not that he had threatened to kill himself.

 

Read full story here→ but note the comments of Dr Cory De Wet (amongst the usual duck-billed platitudes):

“Our staff work hard to assess risk and agree a balanced response with each patient, taking into account their wishes about confidentiality.”

Nonsense! Many staff work hard, but, in this case, aside from the obvious ‘vital interests’ test) Southern Health had broken confidentiality already in telling the family he had an appointment at a mental health unit. Common sense might have been a useful asset too!

Perhaps Dr De Wet, you should work harder to train your staff in matters relating to The Data Protection Act and also tell them to use their common sense if there is a threat to life. ‘Data Protection myths and realities‘ is perhaps one of the best papers published by the Information Commissioners Office:

“Data protection law reinforces common sense rules of information handling, which most organisations try to follow anyway.

“Some organisations understandably err on the side of caution and do not release information when they could do so.”

¹  The Data Protection Act 1998 was replaced by The Data Protection Act 2018 and The General Data Protection Regulations (“GDPR”) from 25 May 2018. Harsher penalties are available under the 2018 Act and GDPR but they cannot be applied retrospectively – or Gloucester Police’s fine might have been even higher.

Spinning around, spinning around

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

CQC report (lower half of page 1):

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

Southern Health’s News Release, paragraph 1:

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

Whirligig icon cartoon

 

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

 

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

Readers can compare the two and draw their own conclusions. 

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

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

2013 MTV Movie Awards

 

(Sorry boys – Royalty Free images, very limited)

¹ Kylie Minogue

Lyrics here