Kangaroo Court

14528651 - illustration of a kangaroo in cage and wooden board


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


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.




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.


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→


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


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?




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. 


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):


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.


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→


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→


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→.


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


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’


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!


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.


  • 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


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.


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:


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


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.


Don’t spit in the soup!

There has been a lot of talk in the NHS recently about freedom to speak up. Read more→

By chance, a friend recommended this book – the inspirational story of Emma O’Reilly, arguably the most courageous whistle-blower of our time – having exposed the truth about Lance Armstrong and doping on an industrial scale. 


The Race to Truth‘ tells initially of the stresses and risks of ‘turning a blind eye’ to doping;  the drive to tell the truth, which led Emma to go public; and the fury unleashed on her – but ultimately it is a story of redemption.

It should inspire NHS whistle-blowers, potential whistle-blowers and anyone with an interest in the duty of candour that should (but all too often doesn’t) exist in the NHS.



Don’t ‘cracher dans la soupe’

This is the paragraph that woke us up to the relevance of Emma’s story to the NHS:

“There was a saying in cycling that you didn’t ‘cracher dans las soupe’ – ‘spit in the soup’: the unwritten rule that you just did not speak out. You do not disrespect the sport… so rebellion of any kind couldn’t be tolerated on or off the road. This was cycling’s omertà – its code of honour. You kept secrets. Those who spoke out risked facing the wrath of the rest of the sport, even of their own teams.”

This is a metaphor for the treatment of  NHS whistle-blowers – except that we’ve not yet heard of any NHS whistle-blowers being labelled a whore and a prostitute.

And without wishing to publish a ‘spoiler’ for those who wish to read Emma’s book, potential NHS whistle-blowers should consider one of her conclusions:

“I’d been brought up to tell the truth … and that in the end the truth always wins.

“It doesn’t matter who you are, or how little you seem, or how long it seems; what’s true is bigger than anyone or anything.” 

Emma also describes, “The sheer sense  of serenity” brought to professional cyclist, Tyler Hamilton when he told the truth after 13 years of denials, lies and cover-ups.

The Race to Truth should be an essential training tool for NHS directors and staff in relation to the statutory Duty of Candour. It is a cracking read for sports enthusiasts too.

And of further interest to medical professionals, over 10 years ago, Emma set up The Body Clinic Hale, one of the most successful private physiotherapy clinics in the North West, dedicated to providing services for the diagnosis, treatment and rehabilitation of all types of injuries and their related problems.

Of course, it’s a great pity that Emma is ‘lost’ to the NHS. What are the chances of a whistle-blower with the courage to take on Lance Armstrong (and effectively the whole of the professional bike-racing community) being given a job in the NHS – especially after a human resources expert at the NHS’s ‘solicitors of choice’ described whistle-blower, Maha Yassaie effectively as too honest to work for the NHS.

‘The Race to Truth’ and Tyler Hamilton’s story, ‘The Secret Race‘ are available from Waterstones, all good bookshops and online: published by Transworld Publishers, part of the Penguin Random House Group of companies, whose Publicity Department has approved this blog post.

© Front cover photograph: Offside/Pressesports



More Southern Health tragedies



Hampshire mother paid £260,000 compensation after finding her daughter’s body: no beds available. Read more→ 

Care-co-ordinator from Romsey Community Mental Health Team to Coroner after loving father found hanging at his home: “If someone needs a bed they will get a bed.” Try telling that to ‘Hampshire mother’ above (and others). Read more→

Family of Word War II hero seeks damages for allegedly, “A distressing and degrading ordeal [for their loved one] brought about by a catalogue of hideous errors.” Read more→

51200916 - platypus or duckbill line drawing vector australian aborigine


Duck-billed platitudes¹



¹ Reference Professor Chris Hatton’s comments on one of Southern Health’s Annual Report and Accounts. Read more→

Appraise a NED!



NED and Daisy at the British National Ploughing Championship


What is a NED?¹ Take your pick:

Non Executive Director

No Effort Detected (UK medical)

No Error Detection (Computing)




Known by some as Non Effective Directors, the Council of Governors at Southern Health did not carry out annual appraisals of its NEDs in 2016 – despite the findings of the Mazars Review and all the other criticism in the public domain. The common thread to public questions at the Board Meeting on 31st January is here→ – ‘The Bad’.

This per se is indicative of an ineffective Lead Governor and Council of Governors. Effective governors were always in a minority; some subjected to bullying; and others resigned.

However, the current Interim Chairman shows promise and has undertaken to complete the appraisals by the end of his current contract, 4th Match 2017 we believe.

We are sure he would welcome evidence-based feedback from bereaved families and other campaigners as well as governors, especially as the majority of governors still appear incapable of holding NEDs to account. One governor wrote of the last Council meeting:

I have firm views on the role of Governors and do not see the governors fulfilling this at the present time. We also have a strange mix of people as Governors. Some seem very ineffectual.”

In short, we cannot rely on the majority of governors to do their job properly in assessing the performance of NEDs.

Dr Sara Ryan² has kindly agreed to publish her observations on the NEDs.sr-email

Anyone wishing to make constructive criticism of one or more NED, can contact the Interim Chairman’s PA at Southern Health or email comments to CRASH in confidence for onward transmission. (CRASH will not forward abusive, malicious or otherwise offensive comments and will not publish any comments without consent.)

Normally, we redact the names of ‘the good guys’ [and gals!] and leave in names of ‘the opposition’. In this case, Sara has agreed we can publish her name and we currently believe the Interim Chairman is a ‘good’ guy too so we do not put his direct contact details in the public domain. His name is already available on Southern Health’s web site.

1 To avoid confusion, in urban lingo NED can stand for a Non-Educated Delinquent.  

2 This blog is dedicated to the memory of Connor Sparrowhawk and recognises the fortitude and dignity of his mother, Dr Sara Ryan in seeking justice.

The good, the bad & the ugly

Copy 19048512_m








On 2 February, your scribe complained about a breach of The Data Protection Act 1998 by the Electoral Reform Services (“ERS”): it had disclosed personal data to Southern Health without the data subject’s consent. After some initial problems with junior ERS officials, the ERS CEO left a meeting at circa 15.50 hrs to talk to the data subject: at 17.32 hrs, she sent the following email to Southern Health:


Error admitted – honest – final response checked with complainant – apology – problem solved – everybody happy – all in about 1¾ hours.

Are you listening Southern Health? You took 880 days even to honour the same data subject’s subject access request. 

And why was this so important? Southern Health did not trust your scribe to keep a promise. The words ‘pot, kettle, black’ come to mind.








There was a common thread to public questions at the Southern Health Board Meeting on 31st January, summarised as follows:

“Can the Executive Directors and Non-Executive Directors in post on 1st January 2016 [shortly after publication of the Mazars Review] find their consciences and resign?”

Similar points were made to the governors at the Council of Governors on the same day.

At the time of writing – the relevant EDs, NEDs and governors must still be looking for their consciences!  What a surprise!









Having attended the National Guardian’s event, we believe we wrote a report that was heavily in whistle-blowers’ favour but recognised the need to give Dr Hughes a chance.

Unfortunately, although whistle-blowers want freedom to speak up, some do not believe in the right for others to do so. I posted a perfectly innocuous comment on one whistle-blowers blog only to have it blocked and be told (amongst other things) by email:

“I neither sought nor expect any support from you.”

Is it not hypocritical for a whistle-blower to preach openness, honesty, transparency and fairness for fellow whistle-blowers whilst censoring fair comment by a patient representative? We pointed out that this blog does not censor comments, provided they are not defamatory, abusive or contain offensive language. We invited her to leave a comment – she has not done so!

She was more intent on finding out if Dr Hughes had invited us personally in order to criticise her. And all this from a whistle-blower who didn’t even attend the event.

Note to other whistle-blowers: we continue to support you and welcome your comments, especially potential and existing whistle-blowers at Southern Heath.







When two members of the public tried to speak to Southern Health’s notoriously unapproachable Lead Governor, during the networking/lunch break between the Board and Governors’ meetings on 31 January, he asked the receptionist to call security!

Is this the same Andrew Jackman, who is Finance Director of Drew Holdings Ltd – a construction company, which boasts several NHS organisations in its client list – a point he fails to declare on his ‘Declaration of Interests’ at Southern Health? Surely not!

Is this the same Lead Governor who covered-up an allegation of misconduct by a NED and fled a meeting like a frightened rabbit because a BBC TV crew was filming it. Read more→ 


The Dilemma of a Whistle-Blower

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

CRASH attended an event for NHS whistle-blowers at the Office of the National Guardian on 20th January. 

WARNING: this page contains a graphic image.




We went to the event already inspired by stories of whistle-blowers and the detriment they suffer. Many of their stories are already in the public domain (some on this blog) but an element of confidentiality, appertaining to those who attended the event, must be honoured. We came away in awe of their courage for which they have paid a huge price.

There were significant reservations expressed in advance of the event about the Office of the National Guardian. Read more on Dr Minh Alexander’s blog and twitter feed

These are just a few personal opinions and perceptions arising from the event.



Negatives and problems


  • Your scribe perceived an air of paranoia¹ in the room, which is entirely justified. The National Guardian has a mountain to climb to gain trust.
  • The current line of accountability for the Guardian does not inspire confidence. Her office should be entirely independent of any NHS-related organisation (including the Secretary of State). The National Audit Office next door would make a good home. It has it’s own hotline – 020 7798 7999 – for concerns about public spending and conduct: unsurprisingly, it is rarely (if ever) publicised within the NHS.
  • Some of those attending the earlier event (largely made up of representatives from health trusts, regulators etc.) are not ‘fit for purpose’ in the context of their own organisations’ treatment of whistle-blowers. 
  • There should have been one event for all stakeholders – or the views of the whistle-blowers should have been heard first: the whistle-blowers felt ‘ghettoised’.
  • There was no confidence in the Care Quality Commission protecting whistle-blowers.
  • Does the National Guardian have sufficient resources to be effective or does she face the same problem the National Data Guardian found on taking up her post? 
  • The National Guardian should not use ‘weasel words’/NHS jargon to soften the meaning of reports. For example, ‘challenges‘ should not be used as an alternative to ‘problems‘ and ‘learning opportunities’ should not be used instead of ‘mistakes’. Mistakes‘ should be qualified on a grade of severity.
  • The problems and mistakes’ appear more serious in the mental health sector.

Analogies on NHS jargon:

Climbing Mount Everest is a challenge: falling into a crevasse on descent is not a ‘challenge‘ – it is a serious, life-threatening ‘mistake‘ and a ‘problem‘.

Shredding/amending a suicide patient’s notes before an inquest is not a ‘learning opportunity’ – it is a ‘mistake‘ (or as one Trust Chairman said, “A cock-up“) of such severity that it might constitute the criminal offence of perverting the course of justice.

Similarly, it is a ‘challenge‘ for NHS staff to have the courage to whistle-blow but it is often a ‘problem‘ for them once they have done so.

Copy 19048512_m


Positives (not many yet).



  • There is good practice: at least one delegate was present who had not lost his job.
  • It is an opportunity to make a difference for those who have already ‘come out’ as whistle-blowers – albeit that it must be treated with due scepticism and, by those who have not ‘come out’, with considerable caution.
  • The Guardian, Dr Henrietta Hughes and her officials appeared empathetic and receptive to ideas – only time will tell.


Whistle-blowers may find some of this contentious (but are welcome to add comments). However, I suggest Dr Hughes should at least given an opportunity by whistle-blowers, especially those who have already ‘come out’, to prove her doubters wrong.

Dr Hughes has requested advice and guidance on the following by 20th February 2017:

  • The criteria to select cases for review.
  • What [are] the greatest challenges of reviewing cases and how to meet those challenges [I know, but we warned you].

Send your suggestions to Dr Hughes by email here or by post to National Guardian’s Office, 151, Buckingham Palace Road, London, SW1W 9SZ. In addition to whistle-blowers, she wants to hear from anyone with an interest in the NHS, including patients and bereaved families. Names of whistle-blowers, who are fearful of speaking up, can be withheld.   

To paraphrase that great man and orator, Martin Luther King:

“Let us not wallow in valley of despair, I say to you today my friend. And so, even though we face the difficulties of today and tomorrow, I still have a dream.

I have a dream that one day even the [NHS], a [body] sweltering with the heat of injustice, sweltering with the heat of oppression, will be transformed into an oasis of freedom and justice.”

38691700 - young attractive female doctor isolated over blue background

2022 NHS Whistle-blower


2017 NHS Whistle-blower


       We should dream too.





¹ In the common (not medical) understanding of the word.