89144385 - woman prisoner isolated on whiteCriminal Convictions

5179554 - a blond woman cat burglar stealing a large diamondOxford Magistrates Court – 20th November 2017

Southern Health picked up its third criminal conviction when it pleaded guilty a to a charge under Section 3 (1) of the Health and Safety at Work Etc. Act 1974¹. The first two convictions are summarised in footnote 1 here→


This Health and Safety Executive (“HSE”) prosecution related to the death of Teresa Colvin at Woodhaven Mental Health Hospital, Hampshire on 22 April 2012. Read more→

The Judge will sentence this prosecution and that relating to Connor Sparrowhawk’s death together to reflect the importance of ‘joining the dots’ between what happened in these cases and for the Judge to understand the extent of Southern Health’s (repeated) failings. Other considerations are consistent sentencing and costs. Read more→

Should Crown Immunity Apply to the NHS?

49651000 - royal gold crown


Crown immunity is a legal doctrine under which onerous legislation does not apply to the Crown.


The Crown” is not limited to the monarch personally: it extends to all bodies and persons acting as servants or agents of the Crown, whether in its private or public capacity, including all elements of the Government, from Ministers downwards.

Therefore, Government departments, civil servants, members of the armed forces and other public bodies or persons are included within the scope of the immunity.

Doctor in ChainsCrown Immunity and the NHS 

Alarmingly, led by the doyenne of champagne socialists and mistress of hypocrisy Polly Toynbee² in The Guardian, there are calls for Crown Immunity to apply to the NHS.


“With medical negligence cases sharply up, citizens need to ask if they really want services drained to compensate a few claimants who can prove their case.”

Reintroduction of Crown Immunity would mean that patients and their families could not claim compensation for medical negligence and Trusts could not be prosecuted for criminal offences.

In fact, it was not until Government passed the National Health Service Community Care Act in 1990 that the NHS came under the full scrutiny of health and safety laws, which apply to private companies. Leading law firm Hodge Jones & Allen writes:

“Looking back at the history of how the NHS lost its immunity in the first place it remains shocking that the Guardian has allowed such a regressive opinion piece to have been published.” Read more of the argument here→

The House of Commons Public Accounts Committee in its report, ‘Health & Safety in NHS Acute Hospital Trusts in England(2nd Report, 1997-98) discussed the effect of lifting Crown Immunity:

“21. The NHS Executive told our predecessors that since Crown Immunity was lifted in the late 1980s, the Health Service had had to live by the law.

“22. [Abbreviated] The NHS Executive told us that Crown Immunity had created a lack of discipline in some places. The NHS Executive put on record, however, that the Health and Safety Executive believed the health service had consistently improved its performance since the lifting of Crown Immunity.”

The NHS Executive also recognised that there had been some “sloppy practices” before Crown Immunity was lifted but recognised also that they still had a long way to go to achieve the sort of compliance with legislation and good practice expected.

It is evident that Southern Health’s slovenly practices continued until 2016. We hope the Mazars Review, three criminal convictions and a new Board of Directors, amongst other things, will transform the Trusts attitude towards the health and safety of customers. 

44734657 - sas word representing special air service and special forces

Crown Immunity in the Military

Compare Southern Health’s three convictions with the death of three soldiers during a special forces training exercise in the Brecon Beacons in July 2013.


The HSE found a failure to plan, assess, and manage risks associated with climatic illness during the training. These failings resulted in the deaths of the three men and heat illness suffered by 10 others. 

Referring to section 2(1)³ of the Health and Safety at Work Etc. Act 1974, the HSE confirmed that the MoD is not exempt from its responsibilities as an employer to reduce the risks to its employees as far as reasonably practicable. However, as a result of Crown Immunity, the HSE could not prosecute the MoD for the failings identified. 

Instead, the HSE issued a Crown Censure to the MoD over the incident – the maximum sanction for a government body that HSE can bring. There is no financial penalty but once accepted is an official record of a failing to meet the standards set out in law. 

So should Crown Immunity be reintroduced for the NHS?

Even without Crown Immunity, we know the difficulty of holding many NHS Trusts to account for their failings.

Do we want a two-tier legal system, in which:

  • Those of us who rely on the NHS for healthcare are prevented from claiming compensation from an organisation that is immune for prosecution, however serious the consequences.
  • On the other hand, those members of society who are fortunate enough to be able to afford private healthcare could bring claims – Crown Immunity cannot apply to a private company?

Additionally, what would the re-introduction of Crown Immunity do for standards of care in the NHS? Standards would inevitably fall dramatically. Crown Censures are no more than ‘yellow cards’ – without a ‘red card’ or financial penalty for repeated offences. 

As demonstrated by the Virginia Mason Medical Centre, opportunities for improvement in care quality and efficiency in the NHS are legion. Patients, families and even the CQC and HSE have few ways of putting pressure on NHS Trusts to improve. Litigation and prosecution are two ways and they should never be removed.


¹ Section 3(1): “It shall be the duty of every employer to conduct his undertaking in such a way as to ensure, so far as is reasonably practicable, that persons not in his employment who may be affected thereby are not thereby exposed to risks to their health or safety.”

²  Polly Toynbee –

“High priestess of our paranoid, mollycoddled, risk-averse, air-bagged, booster-seated culture of political correctness and ‘elf ‘n’ safety fascism” [Boris Johnson].”

Full profiles – Welcome to PollylandDaily Telegraph‘ [26 November 2006]

An opinionated journalist...” – ‘BBC Magazine‘ [24 November 2006]

³ Section 2(1): “It shall be the duty of every employer to ensure, so far as is reasonably practicable, the health, safety and welfare at work of all his employees.



Small steps…

“Patient first is the heart of everything we do. Patient first is our most transformative element.”

This is the mantra of Gary Kaplan MD, Chairman and CEO of Virginia Mason Medical Centre, one of the safest hospitals in the world.

At Southern Health’s 2017 Annual Meeting, a member of the Trust reported two small examples of employees putting customers first – and in one case colleagues too.

Both received a personal, handwritten note from the impressive new Chair, Lynne Hunt.

Card - Liz - Copy (3)


Lynne demonstrates an essential element of Total Quality Management: the way Directors respond to reports of adverse events is crucial to keep employees engaged and help them see the process as personally meaningful.

Directors should sincerely thank employees for reporting incidents and engage them in talking through the incident to help assess the level of urgency and determine next steps.

The Law of Marginal Gains¹:

Nor should low hanging fruit‘ be ignored. The two examples above, on their own, may seem insignificant but the aggregation of marginal gains dictates that a number of small improvements added together result in a significant overall improvement.

marginal-improvement 2Rather than try to improve one aspect of performance by say, 10 percent, instead try to improve 10 areas by 1 percent.

It sounds almost too good to be true – we could all improve by such a small margin!


In any event, whether a concern is “significant” depends on the reporter’s opinion. No act of speaking up should be dismissed until the matter is investigated and leaders know that customers and staff are safe.

Small improvements when added up mean the difference between winning and losing.

Cost and Care:

Baby Birds

Barely a day passes without NHS bodies demanding more taxpayer’s money based on the conventional wisdom that ‘you get what you pay for’. The latest is for an extra £350m/week→ – over £600/p.a.² for each income tax payer. 

This would lead to even more wastage in the knowledge that taxpayers pockets are like a bottomless pit.

However, Virginia Mason has proved that the path to lower cost is the same as the path to safer care. Underlying this is the shared assumption that cost and quality are not alternatives to be traded off, but different aspects of the same ambition to provide safe, effective care on a sustainable basis.

For example, Frontier Economics recently published a report, commissioned by the Department of Health, investigating the costs of unsafe care in the NHS.  A rapid review of existing evidence suggests that the costs of preventable (adverse) events is likely to be more than £1 billion per year, but could be up to £2.5 billion annually. Read more here→

The CQC’s ‘State of Care’ report, which shows massive variation across Trusts, despite similar input costs, also challenges conventional wisdom.

And these also challenge the other commonly held view that only large-scale change will release significant value.

Small steps big changes 2


In 2017, Southern Health made fundamental changes to the Board and published its Quality Improvement Strategy 2016 – 2021.

As they work on major projects, staff need to be encouraged to make small improvements too, which, when aggregated, will make a big difference.




Another essential element of Total Quality Management is that staff can self-report adverse events without punitive consequences. This is not related solely to traditional whistle-blowers.  

If employees realise that their own actions have caused harm to a customer – or could do so – employees should be able to report the incident without punitive action. A defect signals there’s a problem, not with the individual, but in the organization’s processes and systems that care for its customers.

A sign of a fully-effective Total Quality Management system is that Freedom to Speak Up [Whistle-blowing] Guardians are redundant because everyone in the organisation feels safe in reporting adverse events – even if they self-disclose.

We leave the final words also to Dr Kaplan of Virginia Mason:

My conclusion is that too many people still think that providing the best care is something you do only when you can afford it – and fail to appreciate that improving care is one of the best ways to control costs in financially challenged circumstances.

¹ Sir Dave Brailsford – [Harvard Business Review]          

² 30,300,000 individual income taxpayers 2017-18 [HM Revenue & Customs, May 2017]

The Value of Life

57482744 - depressed young man contemplating suicide on top of tall building


26468036 - 3d rendering of a safe full of hundred dollar notes



Let’s compare the cost of remedying a risk to life with other expenditure by Southern Health.






The amount received by firms owned by acquaintances of Southern Health’s former Chief Executive, Katrina Percy, despite winning a contract valued at less than £300,000. Another was paid more than £500,000 without bidding at all. All this spent on Management Development Support, including the ludicrously named ‘Going Viral.’

The trust said it took its financial responsibilities, “Very seriously“. Read more here→ and here→.

Can this possibly be the same Trust found ‘guilty’ at the end of 2015 of a 4-year failure of leadership and governance identified in the Mazars ‘Death’ Review? Surely not!


The cost of employing the top-five earning directors in 2015-16, including salaries, fees, taxable benefits and pension-related benefits:

  • Katrina Percy, Chief Executive Officer
  • Chris Gordon, Chief Operating Officer
  • Dr Lesley Stevens, Medical Director 
  • Mark Morgan Director, Mental Health, LD and Social Care²
  • Sandra Grant (Director of People & Communications)

£1,4814396701 - symbol of euro crash9,000?¹

Cash Equivalent Transfer Value of Dr Chris ‘Lapdog’ Gordon’s Pension Benefits at 31 March 2016.



The cost of employing the top-five earning directors in 2014-15 including salaries, fees, taxable benefits and pension-related benefits:

  • Katrina Percy, Chief Executive Officer
  • Chris Gordon, Chief Operating Officer
  • Sandra Grant, Director of People & Communications
  • Della Warren, Interim Director of Nursing & Allied Health Professionals²
  • Mark Brooks, Chief Finance Officer

Stevens - money 2£987,000?¹

Cash Equivalent Transfer Value of Dr Mystic Meg Lesley Stevens’s Pension Benefits at 31 March 2016.



Sandra with cash & gold 2


Cash Equivalent Transfer Value of Sandra Grant’s Pension Benefits at 31 March 2016: still holding herself out here as a Southern Health Director.



21269245 - a woman is sitting at a table full of money.£521,000?¹

Cash Equivalent Transfer Value of Katrina Percy’s Pension Benefits at 31 March 2016.




Estimated cost of safety improvements required to prevent patients falling off the roof at Southern Health’s Melbury Lodge unit. Apparently unaffordable at the time!

£170,000 – £180,000?¹

33596896 - girl at atm

Payment to Katrina Percy on her resignation! Despite the findings of the Mazars ‘Death’ Review and other compelling evidence, she was considered, “Fit to lead” with:

“No evidence of negligence or incompetence on her as an individual during her time with the Trust that would warrant her dismissal.”


Deemed by all parties, inter alia by HM Treasury and The Department of Health as:

“Fair payment in all the circumstances”¹

Fair Payment – Oh really? £45,000 more than the penalty for risking life!


At Basingstoke Magistrates Court this week, Southern Health was fined £125,000, having pleaded guilty to failing to provide safe care and treatment and failing to assess risk to patients at Melbury Lodge. It was also ordered to pay £36,000 in costs and a £170 victim surcharge.

A patient had fallen off the roof with life-changing consequences yet Southern Health blamed the public spending ‘squeeze’ for its failure to stop vulnerable patients from gaining access to the rooftop.

District Judge Loraine Morgan said:

“It’s a significant concern that even this tragic incident involving AB did not result in immediate steps to prevent any further incident.

“Works were not carried out because money was not available.

“If £300,000 had been spent in a timely manner by the trust, not only could this prosecution have been avoided as would the loss to AB and his family.”

Read more here→.

Money not available your Honour?

Fatcats£5 million spent on questionable Leadership Training; large pay & benefits awards to ‘fat-cats’; huge sums spent on Consultants and Solicitors’ fees (often to defend the indefensible), yet £300,000 not available to safeguard patients from risk of serious injury or death.


And it’s all the fault of government spending pressures! Of course it is!

¹ Source: Southern Health Annuals Report & Accounts 2015-16

² Supplied to the Trust via an external company so only the gross supply cost incurred is know to the Trust.¹

DANGER – Dr Stevens at work!

Men at Work 3


Anyone who thought that Dr ‘Mystic Meg Lesley Stevens no longer has any influence over mental health services in Hampshire – think again! This is a Comedy of Errors!

Dr Stevens now turns up as Clinical Director (Mental Health) of Hampshire & Isle of Wight, Sustainability and Transformation Planning (“STP”):

“Working together to improve mental health services across the area.”

Anyone, who has followed the tragic events at Southern Health from 2011 to 2016, will see the irony in this position being ‘awarded’ to an ex-member of its Board of Directors, which was found ‘guilty’ of a four-year failure of leadership and governance. A second      “Reward for Failurefor an ex-Southern Health Director.

In addition, from incidents during this period, Southern Health recently picked up its first two criminal convictions. Please see footnote 1 below.   

Readers will recall that, on 18 April 2012 [‘Hansard’ 18 Apr 2012 Column 79WH], Dr Stevens, as a member of Southern Health’s Board, was accused in Parliament of allegedly using “Slippery methods” to justify closing Woodhaven Hospital. Her dubious use of statistics led to a serious shortage of beds (with potential life-ending consequences) and huge expenditure on ‘out-of-area’ beds, i.e. referrals to private psychiatric hospitals.

So bewareMystic Lesley is ‘on the march’ collecting statistics again.

Sent: 21 September 2017 11:25
Cc: [30 email addresses disclosed by Southern Health without consent]

Subject: FW: Help us gather people’s views on mental health hospitals in Hampshire and the Isle of Wight

Please see below: for your interest. Please forward on to service users, families, staff and organisations who may be interested in giving views on mental health hospitals in Hampshire and Isle of Wight.

Sent: 20 September 2017 16:22
Subject: Help us gather people’s views on mental health hospitals in Hampshire and the Isle of Wight

Sent on behalf of Dr Lesley Stevens, Clinical Director, Mental Health, Hampshire and Isle of Wight STP and [redacted].

Help us gather people’s views on mental health hospitals in Hampshire and the Isle of Wight

The local NHS in Hampshire and Isle of Wight are working together to improve mental health services across the area. As part of this we are keen to get the views of people using these services, caring for someone who does, or working in them.

Right now, we are interested in gathering people’s views on mental health hospital care. We have made three surveys:

• For service users, carers and family members:
• For members of staff:
• For colleagues in provider or partner organisations:

The information we get from these surveys will help understand what’s working well and where we need to improve services for the future.

We would be extremely grateful if you could help by sharing the relevant survey(s) above within your networks and channels, or with the people you support if they have had experience using mental health hospital services.

If you have any queries about these surveys, or would like to know more about our work, please contact Jo Jones on It would be helpful if we could have as much response as possible by 31 October. Many thanks in advance.

Lesley Stevens
Clinical Director Programme Director, The Mental Health programme of the STP.

It is unsurprising also that, whilst the announcement originated from S.E. Hampshire Clinical Commissioning Group, this comedy of errors was designed by W. Hampshire Careless Clinical Commissioning Group². WHCCG, by its failure as Lead CCG of Southern Health to supervise adequately and demand remedial action, is, in CRASH’s opinion, culpable for many of Southern Health’s past short-comings.

And now the catch. CRASH found several aspects of the survey deeply flawed: CRASH petitioned successfully to have it amended twice and then taken down. Later, when the survey went live again, some of the flaws remained. For example:

  • Woodhaven is not listed as an option in the drop-down box so there is no facility in the survey to petition for it to be re-opened. Of course, this would be seriously  embarrassing for the Mystic one!
  • There is no facility for feedback from patients (and families), who should have been inpatients when no beds were available, sometimes leading to suicide. Of course, this would be distinctly embarrassing for the Mystic one too.
  • The latest version contained a new exclusion, “Secure units” – yet Antelope House, which looks more like a prison that a hospital – even in reception when CRASH delivered a letter there – is listed on the survey but others secure units are not.
  • There is no facility for in-patients (and families) who were referred out of area.
  • Although CRASH was told that feedback from families living outside Hampshire would be welcome, there is no facility for them to do so.

And so on. It is difficult to escape the conclusion that this comedy of errors is aimed at covering up previous mistakes and also justify closing even more beds.

Notwithstanding all this, we should not boycott the survey. We should take maximum advantage of the loopholes – for example:

  • On page 1, if you are a patient (or family) for whom a bed was not available – say that you were and clarify it in the ‘Comments’ box on page 2.
  • On page 2, if the hospital/ward is not named in the drop-down box select ‘others’  and clarify it in the comments box. There is a duplicated question on this page: use it if you wish to comment on more than one hospital.
  • On all the remaining pages, make maximum use of the ‘Comments’ box.

This is the third variation of the same survey so quite how the STP will collate the results is a mystery. One thing is for sure, the resulting statistics will be totally unreliable.

¹ Criminal Convictions

Female Crook 2Basingstoke Magistrates Court – 29th June 2017

Southern Health pleaded guilty to the offence of failing to provide safe care and treatment and failing to assess risk to patients at the unit. This followed an incident in December 2015. The case has been adjourned for sentencing. Read more here→


Ba12163756 - mugshot of pretty witch in police stationnbury Magistrates Court – 18th September 2017

Southern Health pleaded guilty to a charge under Section 3 (1) of the Health and Safety at Work Act 1974. This follows the death of Connor Sparrowhawk on 4 July 2013. The case has been referred to Oxford Crown Court for sentencing. Read more here→

² West Hampshire Clinical Commissioning Group

WHCCG’s cold and unfriendly Chief Officer, Heather Hauschild can be addressed here→

A Death by Indifference

Ryan_Justice-for-Lau_978-1-78592-348-7_colourjpg-printA personal account from the mother of Connor Sparrowhawk, a teenager with autism and epilepsy, who died due to neglect while in a specialist Southern Health  unit. After his death, Dr Sara Ryan started the #JusticeforLB campaign, which uncovered a wider failure at Southern Health and the wider NHS to appropriately care for people with learning and mental health difficulties.

Foreword by Baroness Helena Kennedy QC

© Dr Sara Ryan


Amazon was ‘temporarily out of stock’ already this morning but the book is available also direct from the publisher, Jessica Kingsley Publishers: price £12.99, shipping. handling & tax £2.75¹.  

We cannot find words to describe the book that are more effective than existing reviews:

“A searingly powerful book.” – Sarah Holmes MBE, Patient Advocate

“A salutary lesson on what happens when public services lose their heart and forget that they exist to serve the public and, in particular, be part of addressing the prejudices and disadvantage that are inherent in our society.”
Rob Greig CBE, Chief Executive, National Development Team for Inclusion

“The heart of this story rises above a narrative of private grief and public failure by offering a powerful eulogy to the sheer force of love, especially the personality and character of Connor Sparrowhawk that helped inspire a social movement for truth, justice and accountability. Everyone committed to accountable public services should read this book and learn from it.”
Richard Humphries, Senior Fellow, The King’s Fund

“The echoes of those who no longer speak… no candy coating, it is what it is; a tragedy born from negligence. To quote: ‘At the heart of this story is love’. Love ‘mobilised a social movement’ and love keeps hope alive. Not a good read, a must read.” – Dr Wenn B. Lawson, lecturer and author

And read many more reviews here→.

6304941 - hope and despair with sun rays in this old dark prison cell


However, from the darkness, comes a ray of hope at Southern Health.

There have been so many developments – relating to Connor and Southern Health as a whole – it was quicker to add comments on Sara’s blog. Read CRASH’s comments here→ and elsewhere at



¹ Delivery may vary, depending on location.


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, and its new substantive Chair, Lynne Hunt took up her  post on 3 July – so an ideal time for taking stock of 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


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”).



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


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?