Long Ol’ Dusty Road

Badwater road Death Valley National Park CaliforniaAlthough we have seen little evidence of improvement at Southern Health NHS Foundation Trust, when we wrote the last articlelittle did we know that the long, long road to transformation had hardly started.

We quote text messages from third parties commenting on the evidence given by senior Trust leaders on 1 April – newcomers to the saga might have wondered if they were April Fool jokes!

“5 years on from Mazars and they are now looking at the [Serious Incident] investigation template. She admits the clinicians did not co-operate with investigations and could not see the point of them. They were too busy!!!!! 5 years on and now developing leaflets [for service users, families and carers]!!!”

We remind readers of two key issues in the Executive Summary [14,15] of the Mazars Review [January 2016]: 

“Despite the Board being informed on a number of occasions, including in representation from Coroners, that the quality of the SIRI¹ reporting processes and standard of investigation was inadequate, no effective action was taken to improve investigations during the review period.”

“There was no effective systematic management and oversight of the reporting of deaths and the investigations that follow – it is reasonable to expect the Trust to properly review the need for a further investigation into all deaths when staff have been sufficiently concerned about something which they have then reported to their incident management system.”

So (including Interims) four Chairs, four CEOs and three Medical Directors later and the Trust is still only, “Looking at” the investigation template and producing a leaflet to explain the process to patients, families and carers. One hopes the Panel will grasp the significance of this statement. Who is going to be held accountable? 

One wonders what the Care[less] Quality Commission, NHS [Un]improvement and West Hampshire Clinical Commissioning Group have been doing during this time.

During the week, there was further compelling evidence of the innate bias of the investigation in favour of Southern Health. For example:

  1. The week started with a tirade by Mr Nigel Pascoe baldly asserting that a Southern Health staffmember had been bullied horrendously using Twitter©, text messages and telephone calls. Whilst such conduct cannot be condoned, his silence about the gaslighting and bullying of the bereaved families and other potential witnesses, which led to their withdrawal from the process, is notable. Shaun Lintern of ‘The Independent‘ gives a balanced view here. 
  2. A second incident of a Southern Health executive, who could not make her written evidence available to the public because it contained senstive information – again one rule for Southern Health and another for service users, families, carers and the public. Dr Susie Carmen did the same earlier in the process; see here→.
  3. This week’s ‘score’ – 16.75 hours of hearings, of which 15.5hrs were dedicated to staff and only 1.25hrs to a family member/carer.
  4. Having referred to the Mazars Review again, the true independence of its Review team [page 2] is in stark contrast to the Public Investigation, with its panel heavy with NHS management. 

A Twitter© feed by a current Southern Health service user and potential witness at the Pascoe Hearing has come to light. It demonstrates bullying of current service users too. Starting with the earliest [bold added]:

“Southern_NHSFT why why do you distress suffering despairing people more and more? You are supposed to be improving. Doesn’t say much for all the money you wasted on quality improvement. There are good people working on the ground but zero confidence in the management.

“Last week was despair all created by @Southern_NHSFT. The final straw was to get a letter telling me not to complain about my care on Twitter, not name people I have never named anyone. I started a suicide note I stopped after a conversation and an email from a senior person.”

“Do you realise @Southern_NHSFT that a person who is suppressed and is not able to speak freely,  it is very damaging to ones mental health. I do not want letters telling me they would file it in their legal department because I complained on twitter.”

“There are some excellent people working for @Southern_NHSFT and have helped me a lot.The head of nursing I spoke to and sent me the apologetic email is one of them and many others. There is something inherently wrong at senior level because all the good caring people leave.”

What has happened to this great big Quality improvement programme which cost a fortune. I don’t see any improvement if anything things have got worse.”

“I have done absolutely nothing today, other than talk on the telephone to nice friends and family. My one wish for tonight is to get some sleep. Please @Southern_NHSFT don’t give me any more sleepless nights with your insensitive and inaccurate letters.”

“I feel very strong about injustice, for the past week it has been a tug of war with @Southern_NHSFT, which has worn me down physically and mentally. Came close to my death. Never win justice with organisations that cover up. Is it worth it?”

“I’m trying to be forgiving and understanding about @Southern_SHFT but I’m not a fool because I suffer with my mental health. I’m at a stage where I feel they wiĺl never change in spite of all the money spent on Quality improvement. What it lacks is transparency and honesty.”

“Cannot get to sleep thinking about the letter I received from @Southern_SHFT Meeting tomorrow,  just hope no more cover ups. I am entitled to say what I feel on any platform if I am not getting the support when I reach out. This letter has set my recovery back so much.

So, with letters to the mentally unwell implying the Trust might instruct theirlearned friends‘ resulting in suicidal thoughts and a relapse, how many service users would risk their care by ‘taking the stand’ at a Public Investigation with the Trust’s senior leaders looking on. 

And whilst on the subject of intimidation, as a relatively junior or new manager at Southern Health, how would you feel about criticising the Trust with the Chair, CEO and other Executive Directors looking on?

A final thought:

With five years delays in implementing change, one has to ask if Southern Health (and the NHS in general) is becoming too reliant on technology, systems and procedures at the expense of culture and human factors. We are reminded of the heroic actions of Captain Kevin Sullivan in saving 315 lives on Qantas Flight 72 after one of the aircraft’s three air-data units sent incorrect information to other systems, resulting in a flight control computer twice commanding the aircraft to nosedive towards the sea. The documentary is available here→

Capt. Sullivan quotes Capt. Chesley Sullenberger, pilot in command of US Airways Flight 1549, which ditched in the Hudson River off Manhattan after both engines were disabled by a bird strike; all 155 people aboard survived.² 

USAirwaysFlight1549

“Technology is no substitute for experience, skill, and judgment.”

The two ‘Sullies’ have a point.

Is technology in the NHS a substitute for experience, skill, judgement, empathy and an open culture?

©  Important Notice:

11856530_sa

It has come to our attention that others reporting on Southern Health are culling images from this website without consent. Please see the copyright notice on our home page. We have also found images culled from other websites, including some where the copyright holders are, for example, the BBC, printed media or even the breaved families. 

Footnotes:

¹ SIRI – Serious incidents requiring investigation

² ‘Miracle on the Hudson‘ by Chesley B. “Sully” Sullenberger lll with Jeffrey Zaslow (previously published as ‘Highest Duty“) 

HASC Chickens

“Where are Southern Health’s Chief Executive or the Chair of Governors?”

So asked Cllr David Harrison at a meeting of Hampshire County Council’s Health & Social Care Sub-Committee (“HASC”) on 4 March 2020, when members were asked to not only consider the latest CQC report but also The Pascoe Report.

family portrait poultry chicken, red rooster bright yellow littl

With huge respect to Monty Python – Cleese, Barker & Corbett, “Class System” Skit 1966

The Committee heard deputations about Southern Health NHS Foundation Trust from three members of the public totalling about 25 minutes. The full text of the deputations is available here→.

The only Southern Health employee present during the deputations was Southern Health’s infamous spin doctor, he who acted in an unbecoming and disrespectful manner after the Inquest into the death of Ellie Brabant: BBC South Today report here→.

Readers may have realised already that the CEO, Dr Broughton and Chair, Ms Hunt chickened out. Instead, they sent along a frit Chief Nurse, Paula Hull to ‘face the music’. Her frankly amateurish presentation was in distinct contrast to the re-assuring, confident and professional presentation to HASC by Southampton General Hospital.

It appears Paula is being ‘used’ by the Board for unpleasant jobs – one could have some sympathy for her if it were not for the fact that she would not look any of us in the face!

After Paula’s Report (available here), Cllr Alan Dowden urged members to take action:

“It worries me. We are the select committee and we must do something.” 

Whilst Cllr Mike Thornton stressed that some of the CQC’s ‘must do‘ actions were so obvious that it shouldn’t have needed the CQC to point them out. For example

Biohazard Infectious Waste Safety Sign. Black on orange safety s“Ensure consistency in the disposal of clinical waste in line with policy on handling and disposal of healthcare waste.”

It beggars believe that any hospital does not have consistency in disposing of clinical waste!

 

Others common sense issues in the report, which do not need clinical expertise, include:

  • Ensure all patients have access to a clinical psychologist and psychological therapies.
  • Ensure staff record their decision-making when carrying out mental capacity assessments and ensure staff have a sound understanding of the Mental Capacity Act 2005.
  • Ensure there is a patient alarm system on all older people’s wards, which enables patients and visitors to alert staff to their need for urgent support.
  • Ensure all patients in the crisis service have holistic, person-centred care and a crisis plan in their records. Records must be clear, up-to-date and recorded consistently in the electronic record.
  • Ensure the physical environment of the health-based places of safety are fit for purpose and meet the requirements of the Mental Health Act Code of Practice 8.
  • Ensure the Trust meets its legal obligations in the health-based places of safety.

There was also an important contribution by Cllr Marge Harvey, who has personal experience of unsatisfactory service by Southern Health.

Coincidentally, Health Service Journal reported recently that Simon Stevens might give unearned incentive cash to mental health sector. However, a reader asserts that psychiatry has encouraged ‘mission creep’ of the mental health agenda in a classic example of provider capture and went on to comment:

Before there is any more money, the sector must define what is and is not mental health, how one counts it and how outcomes should be measured. At the moment vast chunks of what is best termed ‘the human condition’ are labelled as MH in the pursuit of various secondary gains. 

Young woman talking with psychologist

Perhaps if Southern Health targeted budgets on psychologists and therapies, it would prevent ‘the human condition’ tipping over to serious mental ill-health. In parallel , it would reduce costs of prescribed drugs; reduce Psychiatrists’ workload; and improve bed availability for those who need it.

 

And finally, one of the ‘should do’ actions prescribed by the CQC is:

  • Ensure there is clear senior oversight of the service, particularly the health-based places of safety.

In the light of these and other ‘must do’ and ‘should do’ actions, it seems bizarre that the CQC rates Southern Health as ‘Good’ in 16 of 18 domains. For example:

  •  How can the ‘safe’ domain be ‘GOOD’ when consistency of clinical waste disposal is  sloppy [pun intended!] and the Trust implicitly is not meeting its legal obligations in health-based places of safety.
  • How can the ‘well-led’ domain be ‘GOOD’ when, aside from the upside-down management structure, there is lack of clear senior oversight of the service, particularly health-based places of safety.

Truly deplorable and unacceptable saga

These are the words of Nigel Pascoe QC in the Pascoe Report on Southern Health NHS Foundation Trust, which is available here→.

Legs of a snowboarder stuck in snow

An upside down, head in the sand snow management structure is illustrated here too.

Our previous post is relevant to the Pascoe Report too. Crucially, Mr Pascoe concludes:

“The long and complex process of the review of this Final Report has brought home to me just how wide the gulf still is between the family members and the Trust. I have sought to express a fair and balanced independent view, whilst continuing to receive sharply opposed submissions. The reality is that deep distrust remains. It is no part of this Report to assess the degree of reputational damage that this Trust has sustained by their actions and failures towards these families. But I retain the hope that an independent limited Public Investigation at least has the potential to change the narrative of a very troubled story.”

In short, Mr Pascoe recommends a two-stage Public Investigation – the first into the death of one patient and the second effectively an investigation into the Trust’s current performance in limited respects. 

Unfortunately, it appears Southern Health’s CEO, Dr Nick Broughton still does not get it (or does not want to get it). He continues to offend bereaved families by implying that, as these are historical cases, he bears no responsibility for the anxiety and stress caused, i.e. a ‘not me guv’ approach.

This was demonstrated when, at the instigation of a bereaved mother, the Portsmouth News changed its article on the Pascoe Report to add to the mother’s comments. 

“Dr Broughton had a real opportunity to resolve our cases but for whatever reason chose another route. His distancing himself from the Trust’s failures to investigate is offensive.”

CRASH’s opinion about Dr Broughton’s sanctimonious and insensitive comments on BBC South Today and in the social and printed media is:

“The bereaved families and I are already concerned by Dr Broughton’s attempt to distance himself on the grounds that the original incidents were historical. He showed no recognition that he could have resolved the issues in the last two years without the need for NHS England to commission Mr Pascoe, no doubt at great cost to the taxpayer.

“The Bereaved Family Group was set up originally by the excellent second Interim Chair, Alan Yates. Rather than conclude the process, Dr Broughton chose to put the bereaved families through two more years of unnecessary distress – and of course Mr Pascoe’s work is still ongoing, whilst Dr Broughton goes on to pastures new.”

Reverting to the CQC Report, it has become evident that one claim is fatally flawed – and, worse still, the CQC knew it was fatally flawed:

“The leadership team had engaged proactively with a number of families who had previously not received the appropriate level of care, consideration and investigation into their loved one’s deaths or poor experience of care (under a previous leadership regime).

“Each family worked with a senior member of the trust’s leadership team…. In late 2018, the trust sought the assistance of NHS Improvement to help address the outstanding concerns of five families….”

13163377 - piglets at trough eatingThis is hogwash: Alistair Campbell would be proud it! It is (at best) a half-truth or (at worst) a terminological inexactitude and (more worryingly) the CQC knows it. 

 

Firstly, it implies the Trust willingly, “Sought assistance” from NHSI. In truth, they only did so at the behest of the bereaved families because relationships had broken down.

More seriously, a meeting in December 2018 was a conspiracy between the Trust, NHS England and the CQC to silence the families, not help them. A bereaved father writes:

“Understanding the barriers to progress to be wider health system issues we [his wife, another bereaved father and a supporter] were instrumental in establishing a meeting between Dr Broughton and Ms Hunt of the Trust, Dr Lelliott [CQC] and Professor Kendall of NHSE in December 2018. The stated purpose of the meeting was to explore what these barriers were and attempt to find ways around them. In effect we were committing to continuing to work with the board in our own time and at our expense in order to gain assurance that lessons were being learned and real improvements in service made.

“Sadly, the meeting did not go to plan. We were treated with utter contempt by Professor Kendall and Dr Lelliott and essentially told to go away and mind our own business. Ms Hunt did appeal to us to act as critical friends of the Trust, an offer I personally accepted on the spot, only to be rudely rejected by Dr Broughton. That is where my direct engagement with the Trust ceased [bold added].”

The father submitted evidence to the recent CQC inspection, including a reminder of this event. Yet the CQC still had the audacity to publish, what it knew was false statement.

Duck looking for food in a lake

It shows an upside-down management structure too: the CEO over-rides decisions of the Chair! The Chair cannot control her CEO. This does not characterise what the CQC claims to be a well-led regime.

 

So Dr Broughton continues to add to this, “Very troubled story” – but then he’s already jumped ship. The timeline suggests he first saw a draft of the Pascoe Report in or before November 2019. At the same time, he would have known about the CQC’s over-flattering report. He leaves in May – six months later (possibly a contractual notice period).Nick B

So – November 2019, a good time to apply for another job, Nick!

Surely not.

 

Care[less] Quality Commission

124487987_sInitially, this post was planned to challenge the accuracy of the latest Care Quality Commission Inspection Report on Southern Health NHS Foundation Trust and the flattering media reports, which followed, such as in ‘The Oxford Mail’→

However, sources close to the NHS have informed CRASH that an independent report by leading Counsel will shortly be published by NHS England or NHS Improvement and that this report will in itself disabuse the CQC of many of the claims it made about the Trust.

The report was circulated today – but withdrawn within an hour – not before it had been leaked anonymously. However, in fairness to those involved, we will not comment until it is republished. Instead, we will let the CQC’s recent record speak for itself. Readers can decide, which of the categories in the above image apply.

In November 2019, the Joint Parliamentary Committee on Human Rights (“JCHR”) published its 2nd Report (2019 session). The JCHR heavily criticised CQC inspections an, at chapter 7, point 157 of the report concluded of the CQC:

“A regulator which gets it wrong is worse than no regulator at all.”

Also, the JCHR also concluded at chapter 7, points 123 to 157, (amongst other things):

1. The CQC, as regulator, should be a, “Bulwark” against human rights abuses of those detained in mental health hospitals. Its ability to protect patients against human rights abuses is, “Impaired” and, “Urgent reform” of its approach and processes is, “Essential”.

2. Concerns raised by patients and family members about treatment must be recognised by the CQC as constituting evidence and acted upon.

3. A review of the system which currently allows a service to be rated as, ‘Good’ overall even when individual aspects, such as safety, may have a lower rating.

The JCHR’s inquiry was triggered in May 2019 when BBC Panorama exposed serious abuse and mistreatment of vulnerable adults at Whorlton Hall. The CQC’s then-deputy chief inspector of hospitals, Dr Paul Lelliott told Panorama:

“On this occasion it is quite clear that we did not pick up the abuse that was happening.”

Health Service Journal analysis also showed that, after the Whorlton Hall scandal, the CQC down-graded six mental health hospitals to, “Inadequate, just months after describing them as either, “Good” or, “Outstanding”!

The CQC also rated Norfolk and Suffolk Foundation Trust, “Requires improvement” for whether services were safe, responsive, effective and well-led and, “Good” for whether services were caring. But Healthwatch Suffolk said there was:

A disparity between what the trust reports, the outcome of this inspection and the experiences of service users and carers”.

And the local service users’ champion said it had noticed: 

“Very little improvement in peoples’ recorded feedback”.

Sick Bag 2

And what happened to Dr Paul Lelliott after all this. Why, of course, early retirement to go travelling, financed no doubt by a healthy pension pot, and a gong in the New Year’s Honours List.

Pass the sick bag!

 

However, the evidence suggests these criticisms can be levelled at the CQC’s latest inspection report on Southern Health, despite the appointment of a new Deputy Chief Inspector Mental Health & Community Services, Dr Kevin Cleary. CRASH knows that Dr Cleary and his inspectors had evidence, which they clearly ignored. Wilful blindness?

Moreover, as recently as 21 January 2020, ‘The Times’ reported that, during an audit, the CQC found, “Duplicate material” in 78 reports, with identical quotations from patients or sections of evidence pasted into reports on different institutions. As a result, the CQC has decided to carry out several re-inspections. Read more here→

In all the circumstances, the CQC report on Southern Heath, which (in our opinion) deflects the truth and contains terminological inexactitudes¹ should be treated with a huge bucket of salt.

We await the new report but it begs the question – did Dr Nick Broughton jump ship before the truth was out?

On an entirely different subject, Sir Keir Starmer MP told BBC News:

“I know from running a big organisation that, if you’re going to change the values and the culture of the organisation, you’ve got to do it from the top down”

No-one doubts there are dedicated and caring staff working at the coal face in Southern Health. What the ‘new leadership’ has failed to demonstrate is a good culture at the top.

The leadership could also learn from The Military Leader², who wrote under the heading ‘Systems that Strangle‘:

“Teams and their members take fewer risks and stop fighting for new insight when they have processes to protect them. It’s not intentional, it’s a function of our innate propensity to seek homeostasis…a comfortable, predictable environment.”

Yet all we see at Southern Health are lots of systems, planning, strategies, consultations and meetings but no change in culture!

Broken Trust

In short, CRASH is not alone in believing  Southern Health remains, what the BBC termed, a, ‘Broken Trust.’

The CQC should be downgrading Southern Health just as it has downgraded six others.

 

¹ Terminological inexactitude [Winston Churchill  1906 and (unsurprisingly) William Rees-Mogg 2018!]

² The book, ‘The Military Leader’ is available from Amazon and other bookshops. With more than 20 years of combat-tested leadership experience, Andrew Steadman knows what it takes to build teams and grow leaders. Drawing from his highly successful career as an Army Infantry officer, he wrote ‘The Military Leader’ to be a foundational leader development resource for leaders of all professions.

A reviewer on Amazon comments:

“An excellent book on leadership! The lessons and techniques can be used by leaders in all industries and organizations.”

Having read the book, this comment applies especially to leadership in the NHS.