Candle in the Wind

two candles with dark background

Dr Bill Kirkup CBE, whose evidence to the Pascoe Investigation into Southern Health NHS Foundation Trust was reported here, was followed by two more equally authoritatve and credible independent witnesses, Dr Josephine Ocloo and Keith Conradi.


Dr Jospehine Ocloo

Senior Researcher & Health Foundation Improvement Science Fellow at King’s College, London, Dr Ocloo became involved in patient safety after her daughter died following a medical failure. 

This gives her a high profile role as a patient representative and patient safety researcher. She completed a PhD in 2008 on medical harm from the viewpoint of those directly affected by safety incidents. She emphasised the, “Awful grief” experienced by bereaved families, subsequent betrayal by the NHS, causing, “Further grief.” She described this as,

The dark side of the NHS” [adding]

“This will keep happening until it the NHS is fatally wounded.”

Will the Panel identify the irony in Dr Ocloo’s comments? The families’ original withdrawal statement and their refusal to re-engage, demonstrate that the Pascoe Investigation is yet another act of betrayal – this time by NHSEngland/Improvement. Read more here→

house sinking with a downward arrow on background, verticalDr Ocloo used the analogy, ‘You can’t build anything on sand.’ The foundations must be right.

We summarise some of her insightful views, as noted:

  • The Duty of Candour will not work without remedying the root cause – a closed culture with no transparency.
  • Defensiveness and unwillingness to ‘own up’ prevents openness and transparency too.
  • There is no commitment in the NHS to Article 2 (The Right to Life); families are seen as the problem. Trusts need to own up and settle.
  • There is no commitment to openness and transparency – starting with the leadership.
  • There needs to be the right balance between accountability and learning – this is essential in a democratic society.
  • Trusts are large corporate bodies with many opportunities and resources to cover up their failings.
  • The architecture of governors, non-execututive directors (“NEDs”) and Executive Directors is driving the problem. NEDs often lack true independence; governors have little influence and are unable to challenge effectively.
  • Patient/public engagement has been mooted since 1970. It doesn’t work; it excludes the most vulnerable, including Mental Health and Learning Disability patients.
  • Complaints are not investigated independently: the PHSO is ineffectual. Families are let down by everyone; excluded from investigations; and treated, “Brutally.” 
  • Recent and old cases are remarkably similar.
  • There should be statutory complaints regulations with investigators completely and truly independent of the Trust, including laypeople from outside the NHS.
  • There needs to be a cultural shift in Regulatory bodies. All are perceived by the public as ineffective – endless criticisms of them are not addressed.
  • Laypeople are not involved sufficiently in all areas the NHS, including investigations. 
  • Service users, families and carers have no-one to turn to for robust assistance. 
  • Has heard of a ‘cultural shift’ but there is no genuine contrition. Culture can only be judged by service users/families – their perception is key. 
  • Harmed patients are not considered important but trusts cannot learn without them. Some families are prepared to ‘cross the barrier’. 
  • In 2016, circa. 80 bereaved family members attended a meeting about a proposed Learning Disabilities Mortality Review (LeDeR) Programme¹. There is no evidence of any recommendations being implemented; 5 years later, “LeDer has stalled.”
  • In 2017, the Care Quality Commission said there was no organisation running complaints systems properly: doesn’t think there’s been much progress since. 
  • Even she [a patient representative and patient safety researcher] struggles to be involved at a senior level.
  • Ideally investigators of serious incidents should be completely independent of Trusts and the NHS. This should include natural deaths to check nothing is being covered up.
  • Families should have access to legal advice to overcome an imbalance of power. One side has legal and medical experts; grieving families have nothing. 
  • Patient safety issues are not opened out from the Trust. Healthwatch might give public input but have no remit to hold Trusts to account.
  • There may be salvation in Integrated Care Systems if there is family and patient representation.
  • There should be diversity of investigators², including lay voices, and a medical expert.
  • The “Just Culture” currently is geared to staff interests rather than patients/families.
  • It is not a psychologically safe system – ‘the Trust is always right‘. Staff who speak up are gaslighted and treated brutally. 
  • Children, adolescents, and elderly often get missed out. This is little support during investigations – independent advocacy does not work.

Dr Ocloo feels the most fundamental issue is that investigators must tell families: why an incident has occurred; if it was preventable and; who is accountable. She recommended  Trusts should look at the commercial world to learn about investigations. We know many isues at Southern Health remain unresolved – the bereaved families’ issues for example.

She recommended a ‘Truth Commission‘, provided that both parties are willing to engage in good faith – as in the South AfricanTruth and Reconciliation Commission.’

cropped 12010377_s image requested

Keith Conradi 

Chief Inspector of the Air Accident Investigations Branch (“AAIB”) (2010 – 2016), Keith has been a professional pilot for 40 years. He is current Chief Investigator of the Healthcare Safety Investigation Branch (“HSIB”).

Keith made a stark comparison between aviation industry’s attitude to safety incidents and that of the NHS; it became clear when he became founding member of HSIB in 2016.

  • There is evidence that NHS investigations attempt to avoid liability. The AAIB assumes people come in to do a good job and do not to blame individuals for honest mistakes. 
  • There should be a culture balance between a learning culture and accountability. The latter usually is carried out by regulators. 
  • A single regulator Civil Aviation Authorityensures the whole aviation industry meets the highest safety standards. Accountability in the NHS is too complex and fragmented with too many regulators and no straight line of accountability.  
  • International Air Transport Association (“IATA”) is a powerful, unified and experienced voice supporting and promoting the interests of aviation worldwide, and setting overall standards for members. There is nothing similar in healthcare – even in UK.

Notwithstanding the importance of a single national regulator, Keith emphasised that a strong and accountable Board is essential in large Trusts. The most successful are where Board Directors show a keen interest in safety incidents and complaints.

During his time at the AAIB, Keith felt easyJet was the best performer. He credited the CEO, Dame Carolyn McCall, DBE for taking a personal interest in all safety incidents. 

Carolyn-McCallIt is no coincidence that under her leadership easyJet achieved record passenger numbers and record profits. 

In 2013, Flight Global gave Carolyn the Airline Business ‘Airline Strategy Award for Low Cost leadership’.


Who said Lean Management, cost-saving and safety are mutually exclusive terms?

Interestingly, just as the panel asked Dr Kirkup if his experience clouded his judgement of the NHS overall, a Panel member questioned the validity of comparing the aviation and healthcare sectors by claiming that healthcare is far more complicated. 

We beg to disagree – if there is a serious incident involving a Boeing 747, the aircraft (with six million parts), crew, airline, manufacturer, air traffic control, airport, cargo, check-in staff, ground handlers, meteorologists, engineers (and so on ad finitum) all are considered as possible causes. Investigating, for example, deaths by ligature, is simple in comparison.

We summarise some of Keith’s other views, as noted but in no particular order:  

  • Families want a true account of what happened and accountability; they don’t want repeated mistakes. A separate organisation should hold Trusts accountable. 
  • In investingating complaints, a current employee of a Trust cannot be independent. There are huge issues with perception, which are very difficult to overcome.
  • Leadership of the investigation is key – one can be a good leader without being a safety expert. The leader does not have to be from the healthcare sector. 
  • Local investigators need better training. At HSIB, new investigators do 3-weeks’ intensive classroom training before shadowing an experienced investigator. Then, they are allocated to a team but remain accompanied until judged sufficiently competent.
  • Family engagement essentail: every time. It is key to keep them in picture and prvide key information. They know more about the culture of organisation and provide invaluable and insight on improvement. 
  • Families should always get opportunity at face-to-face meetings to comment on draft reports. If they disagree, both views must put both into the report.
  • On Duty of Candour, it is sad there has to be a legal obligation in the NHS: 

  “Honesty and family involvement are essential as human nature.”

  • Overall Compliance with the Duty of Candour is the responsibility of the Board, which should take immediate action on breaches.
  • The HSIB has been a slight improvement in culture but only where it has carried out investigationes. There is talk about a just culture – but only relating to staff safety.
  • An accountable Board is better for local complaints. A health and safety expert should sit on the Board; the CEO should sit on the Trust’s Quality & Saftey Committee; and there should not be so many on the Committee that it dilutes responsibility.
  • The Board should check very early that action plans have been implemented. This cannot be effective if complaints are not taken up to Board level. [Southern Health has just divisionalised complaints, shifting responsibility farther away from the Board.]

Keith described the HSIB’ limitations as a, “Small agency” on a non-statutory basis, with funding of £4.5m and 45 employees. The HSIB is placed in NHSE/I but they have no say in what the HSIB does except, for example in planning, resources, and personnel services. NHSE/I can allocate additional resources for special projects. 

We would that, if NHSE/I allocates HSIB’s funding, they have significant control over what HSIB can achieve. We believe HSIB should be put on an independent statutory basis and allocated significantly increased funding. Keith would not be averse to increasing the HSIB’s role, perhaps with a regional team and a register of trained, accredited independent investigators for Trusts to choose from. CRASH says, “Bring it on!”  

We make no apology for this post being lengthy and staid – the evidence of Dr Kirkup, Dr Ocloo and Keith Conradi is key. It is for the Panel to determine how closely Southern Health meets their requirements and thereby demonstrate its true independence.

In memory of all Southern Health’s patients, whose lives have been lost. We can only hope.

Candle of Hope2

And it seems to me you lived your life
Like a candle in the wind
Never fading with the sunset
When the rain set in
And your footsteps will always fall here
Along England’s greenest hills
Your candle’s burned out long before
Your legend ever will.4


¹ LeDer was the world’s first national review of deaths of people with learning disabilities. Commissioned after the findings of the ‘Confidential Inquiry into premature deaths of people with learning disabilities from 2010-2013’, the Mazars Report on deaths of learning disability and mental health patients under the care of Southern Health Trust re-emphasised the importance of the programme. Read more here→

² Diversity issues at Southern Health are not limited to the 9 protected characteristics. In practice, they engage only with compliant customers and reject those with the knowledge and management expertise to identify improvement opportunities and assist implementation.

³ Elton John, Bernie Taupin [1997] 


Sideshow: 1. A minor show or exhibition in connection with a principal one, as at a circus.  2. Any subordinate event of matter.¹

So the Public Hearing into Southern Health NHS Foundation Trust, which resulted from the deaths of five vulnerable people, opened with an odious statement by Mr Nigel Pascoe QC relegating the bereaved families to a sideshow – a subordinate event. A fully copy of his statement (for publication) is here→

Amongst other objectionable parts of his statement is:

“As Chair of this investigation, I have decided today not to make any comments on either of the responses given by the families. To do so would be to prolong their agony, with the added danger of creating a sideshow.”

And yet, relegating the families to a sideshow and not explaining their failure to reengage, did exactly what he claimed he wanted to avoid. Family members who watched his statement were so upset that they are unlikely to log in to the hearing any more.

One of Mr Pascoe’s more objectionable comments concerned the Panel Members:

“I have no doubt whatsoever that they cherish their independence.”

Changing the gender in Hamlet by William Shakespeare: 

The man doth protest too much, methinks”²

It insults the intelligence of the families, the media and the public. A TV reporter has already identified it. It is a key reason why the families withdrew – no wonder Mr Pascoe refused to expand on the subject – and didn’t even allow the Panel Members to introduce themselves so the public could judge for themselves. The families’ full statement is available here and we quoted subsequent statements here. The families asserted specifically:

“The idea of spending a few more months locked into an exploitative relationship devoid of trust, with people who mock the word independence [our emphasis].”

For good measure, Mr Pascoe engages in the NHS-practice of media/family blame:

“Nothing will deflect us from pursuing that objective, no matter how much noise there is in the public arena.”

The, “Noise” Mr Pascoe was (amongst other things) caused by NHSE’s failure to produce Terms of Reference (“TORs”) that met the families’ expectations and a panel, which no reasonable person would perceive as indepenedent. And you, Mr Pascoe agreed them.

No wonder Mr Pascoe did not want to address the families withdrawal in detail. Clearly, it had more to do with concealing the fatal flaws in the TORs and procedures. His statement served only to prolong their agony.

Here are some comments about Mr Pascoe’s opening statement by bereaved family members [unredacted, save for identities, with emphasis added}:

Family member 1.

“Thank you for sending this slimy statement – it is interesting insofar that Pascoe clearly feels compelled to explain and justify his decisions !!!!! And he does so (notably in the same manner as the [unsigned] panel statement) without explaining what is meant by ‘CONSTRUCTIVE CHANGE’!!  His claim that he was left with just ‘two choices’ is plain bullshit as if he  had he actually carried out an investigation into the ‘quality of investigations’ he would have found more urgent issues to consider than Trust policy!!!!!!!!!

Family Member 2.

“Thank you [CRASH] for your work and support, without you we’d have none whatsoever. 

“You’re right, his opening statement made me feel totally vindicated for removing ourselves from this deeply biased, heinous process.  I would not want him or the ‘not so independent’ Panel to sully the memory of our deeply loved, beautiful [redacted].” 

Family Member 3. 

“Thank you for taking the time to send this on to us. I will be interested to see the outcome and whether anyone will actually ask why we didn’t go ahead?

Don’t hold your breath!

TV Journalist.

CRASH spoke to a TV reporter on the second day of the Hearing. It was an interesting conversation. She agreed the lack of independence of the Panel, commented on the small number of service user/carer witnesses, and the unconvincing  procedure. 

The Daily Echo reports (here) that one bereaved family member is so distressed by this charade that she has written to the Prime Minister and Secretary of State asking for a genuinely independent investigation. 

Witnesses:  Thumbs down

In talking of witness numners, the TV reporter was spot on. Also Trust witnesses did not inspire confidence that they had a grasp of their brief.


We should however express sympathy for Julia Lake. She became Deputy Director of Nursing when the formidable³, Florence Nightingdale Scholar, Sara Courtney left about four months ago. It reflects poorly on Southern Health’s leadership that they cannot retain the services of a well-respected officer and put up a new appointee for such an onerous and stressful task.   

It was notable also that witnesses were asked to attest that they would tell the truth but there was no means of checking if they were doing so. We will go no further now than saying that several questionable statements were made to the Panel.

Laughing with tears and pointing emoticon

Others were simply laughable.

None were challenged.



Thumbs logo - greenService User Witness

Credit must go to service user, Mr Matt White who made five extremely  good suggestions.


As there is no recording or transcript available to the public, I hope I have noted them accurately. They are excellent ideas. Matt started by asking how to complain about the complaints department – that speaks for itself! He had reached five conclusions!  

  1. Moving forwards, staff should follow their employers’ policies, first and foremost. [Otherwise] it’s a pointless document. [Applies to Directors as well as staff. Ed.]
  2. Professional negligence insurance should be available for complaints handlers/investigators [Not clear on this one. Ed.] 
  3. Clinicians should record their thought processes in patients’ medical records as well as facts and decisions.
  4. Evidence suggests that the complaints department should itself be independently investigated.
  5. Selection & Training of investigators needs to be more robust with accountability. Second investigator not up to the job: when challenged went silent.

Matt, who has questions unanswered since 2017, said that the complaints process was very hard work; damaging to him; not made easy; still has unanswered questions. He had seen no improvements since 2017. He still feels no closure or resolution and feels he has exhausted all options. He referred to deep psychological and emotional harm.

Matt hit the ‘nail on the head’ – staff (including leaders) don’t follow policies and the complaints department itself needs independent investigation including of its supervision – hopefully more independent than this charade. The families reasons for withdrawing included the TORs only allowing the Panel to consider the robustness of policies – no point in that because the Trust (including leaders) often pay scant (or no) regard to its complaints policies and procedures anyway.  

And finally:

For those who wish to form their own opinion, next week’s schedule for the Hearing (including witness details) is here 9 – 11 March witness schedule for publication. 

Links to the hearing (on Microsoft Teams©) are available from the Panel Secretary, Alice Scott – 


¹ Sideshow | Definition of Sideshow at

² A cynical, ironic, somewhat sarcastic comment about someone overdoing a denial, suggesting that they are, indeed, to some degree guilty.

³ We interpret ‘Formidable selectively as, “Inspiring respect through being impressively capable” as in, “A formidable upholder of service users’ rights.” We do not mean, “Inspiring fear through being impressively large!!!”   

Basil Fawlty?

Time to Fact Check Dispel Rumors Find Truth Clock 3d Illustration

We planned to fact-check Mr Nigel Pascoe QC’s Stage 1 report, having found a glaring error. However, it has become more important to fact-check the process for Stage 2, which is fast becoming Fawlty-esque. So, we will update the story with news links; correct the error in the Stage 1 report; and finally fact-check the procedures for Stage 2.

‘Nursing Times’CNO replaced as senior responsible officer in Southern Health inquiry

Another courageous report on Chief Nursing Officer for England, Ruth May – now standing down as Senior Responsible Officer (“SRO”) for Stage 2. Did thIs follow the robust criticism in the ‘Nursing Times’ first report? Surely not!  Free access to the Nursing Times here→

‘Daily Echo’ – ‘Bereaved families ‘lost trust’ in NHS

Valerie Walsh – a Southern Heath employee compares her treatment for mental health with her stay in an acute hosital. Her Tweets from 17 September to 3 October 2020 are telling. We met Val in 2016, just after she resigned from Southern Health to protect health – yet she still had the dedication to rejoin. Read more here→ and here→.

Pascoe Stage 1 Report – Fact Check – The Triangle of Care

On p.175 of the Report, Southern Heatlh NHS Foundation Trust claims:

“Triangle of Care, a national initiative, launched in 2010 by the Carers Trust for mental health and inpatient services was re-launched in Adult Mental Health services (2018).”

This is wrong: CRASH questioned the Trust’s use of the Triangle of Care logo in November 2019. On 17 November 2019, a senior official from Carers’ Trust replied:

“I have looked into the issue you raised and I can confirm that Southern Health NHS Foundation Trust have applied to become a member of the Triangle of Care community.  They are currently undertaking level 1 which is focused on inpatient services. They have until mid-July  2020 to complete this phase which will then be reviewed by a team who have gone through the process and are outside of the South West to ensure independence.  The review team will include a carer. If they are successful they can go to level 2 which focuses on community and crisis services.

“I have also been in touch with the Trust and asked them to take out the two stars from the Triangle of Care logo which they have done. They have apologised and assured me this was a genuine mistake by the person who put it on the website because they had insufficient knowledge of the scheme.”

So the Trust told the Panel that the scheme had been re-launched in 2018 but one year later the Trust had not been approved; was misusing the logo; and had up to another 6 months to complete the approval process. I believe that the ‘re-‘ in ‘re-launch’ is misleading per se

It is interesting to note the Trust’s excuse that it was a, “Genuine mistake.” In November 2019, Mr Pascoe’s Stage 1 Report was still in draft form. There cannot be two, “Genuine mistakes” so Trust Board Members could have rectified this ‘mistake’. 

Stage 2 – Fact Check  

It is evident that even the procedures for Stage 2 have not been fact-checked. For example:

1. When a potential witness asked the new SRO Aidan Fowler for a copy of the Mental Health Act 2005, which was quoted in the papers, he supplied a link to the Mental Capacity Act 2005. The Mental Health Act 2005 does not exist. Might this error result from his ‘trade’ – a Consultant Colorectal Surgeon? At least, if stress from this process causes anyone to suffer severe haemorrhoids and constipation, perhaps he can help!  

2. In ‘The Daily Echo’ on 12 February, Medical Director Dr Karl Marlowe is quoted: 

“We encourage anybody who wants to share their experience to contact the Panel directly.”

Funny that – the deadline was 10a.m. on 11 February!

3.  Originally, those meeting the 11 February deadline were to be informed on 12 February if the Panel required a full written with statement and evidence. Then, witnesses would have until 17 February (two working) days to submit it. However, on 12 February, we learned that the deadline had been extended until 4pm on 22 February!

Great, you might think! However, how many potential witnesses didn’t register originally knowing believing they would have only two working days to submit full statements and evidence. The fragrant Ruth ‘Stay Home This Easter’ May was aware of concerns about unrealistic timescales months ago.

4. There is a mystery over the status of the new SRO, Aidan Fowler, too. Whilst using NHS notepaper for this purpose: 

“Since March 2020 he has been on secondment to the Office of the Chief Medical Officer, Professor Chris Whitty” [source:]

Of course, Professor Whitty is currently committed to COVID-19, aided by his three Deputy Chief Medical Officers, two of whom we have seen at Number 10 Briefings – the ever-impressive Professor Jonathan Van-Tam, along with Dr Jenny Harries. Whilst Aidan Fowler, who clearly is engaged in Covid work too – even writing articles for the press and being named on Professor Whitty’s profile.


Who should be more concerned?

The public for the risk of distracting a Deputy CMO from Covid or the bereaved families for the risk of Covid distracting the SRO?

More on Mr Basil Aidan Fowler to come.


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.


Planning to Fail

dav© James Whitworth¹

In February this year, Dr Nick Broughton, CEO of Southern Health NHS Foundation Trust produced a Briefing Paper, effectively an Action Plan to reduce the number of Out of Area Placements (“OAPs”)² to circa. 20 before the end of 2019. It is already well off target.

It incuded a colour-coded graph, which we have updated from later Board Papers:

  •  Red – actual OAPs by month to December 2018.
  •  Blue – projection to March 2020 with full effects of Southern Health’s actions.
  •  Green – projection to March 2020 with full effects & housing available for patients ready for discharge.
  • Purple – actual OAPs to September 2019 and the October trend. Off the scale in August 2019! 

OAP Graph - Copy

How can the public have confidence in the management when a plan they prepare in February goes so spectacularly off target so quickly?

But Southern Health’s November Board Papers state that the Trust’s block contract for OAPs at the Marchwood Priory has been increased to 17 until March 2020 and it is currently negotiating with Elysium Healthcare for the provision of 5 female PICU³ beds in Newbury, Berkshire. (Actually, it appears to be in Thatcham!)

With the contract with Solent NHS Trust for 6 beds, the contracted total OAPs will be 28.

That’s over twice the projected figure even without extra-contractual beds! And the year to date spend of £4.8m (to Augst-end ) compares to a budgeted figure of £2.7m.

BUT BEWARE is skulduggery afoot? 

Ominous notes in Southern Health’s November Board Papers suggest that OAPs to The Marchwood Priory and Solent NHS Trust will be excluded from the future overall  total of OAPs figures. What’s more, this allegedly conforms to NHS England guidance. 

Yet, the Department of Health publishes a very simple decision tree, ‘How to decide whether an admission is an OAP.’ It states unequivocally that an OAP includes when:

“The patient is being admitted to an inpatient unit with another provider.”



Perhaps both Southern Health’s and NHS England’s CEOs are attempting to minimise the bad news ending up on the Secretary of State’s desk. They should reflect on the words of Life Coach, Lindsey Ellison:


“When you cheat on yourself, it’s the ultimate betrayal. It means you don’t value who you are. You don’t respect your boundaries. You think you’re aren’t good enough.”

We complimented Dr Broughton for his comments after Mr Justice Stuart-Smith’s sentencing in R v Southern Health NHS Foundation Trust so we should also compare his performance with undertakings he gave and his comments about engagement with campaigners. We reflect on the very positive comments he made then about members of The Forum for Justice, Accountability & Equality at Southern Health and others.:

Crucial to these and other improvements is the contribution from many families and individuals dedicated to bringing about change. Whether working alongside us, or indeed as campaigning activists, their courage, dignity and insight is making a difference and deserves recognition.”

Now the honeymoon period is over, he treats CRASH and other members of the Forum with open hostility  if we dare challenge him.

Fake News neon sign vector. Breaking News Design template neon sign, light banner, neon signboard, nightly bright advertising, light inscription. Vector illustration


We do not intend to make a political point but we nearly choked on statement by  quirky New Forest East MP, Rt. Hon. Dr Julian Lewis in a recent election flyer:

“Julian continues to campaign on , and monitor, such major local issues as mental health acute beds, community hospitals and the future of Dibden Bay.” 

Oh really? Whilst Dr Lewis was prominent in campaigning against bed closures in 2012 [Hansard 18 Apr 2012 : Column 79WH], the latest OAP figures suggest that, whatever effort (if any) he has made to this end, has been ineffectual.

Later [Hansard 8 June 2016 : Column 149WH], Dr Lewis contributed only reluctantly:

“I hesitated to contribute to this debate because I have not been involved in the
cause of the current crisis, which is about the deaths of patients being
insufficiently explained.” 

And when the excellent Suella Braverman MP sent a letter to Dr Broughton, counter-signed by other Hampshire MPs, Dr Lewis’s signature was notable by its absence.

In short, Dr Lewis worries about his own agenda but, “Hesitates” when deaths are not properly explained. Can he not see the link between bed shortages and patient deaths?




Special thanks to James Whitworth¹ for allowing use of his cartoon on a complimentary basis.




¹ Whitworth cartoons regularly appear in national newspapers as well as a wide variety of magazines including Private Eye and Prospect. He is a nationally syndicated cartoonist with daily topical cartoons appearing in newspapers from Edinburgh to Portsmouth. He also provides bespoke illustrations for Business, Marketing, Presentations & Publications.

View examples of Whitworth cartoons here:  several reference the NHS including one directly relevant to Out of Area Placements, i.e. bed occupancy.

² OAPs can be split into two categories – appropriate and inappropriate.

  • ‘Appropriate OAPs’ occur if a patient is admitted to an inpatient unit with another provider but in the same geographical area.
  • ‘Inappropriate OAPs’ occur if a patient is admitted to an inpatient unit with another provider outside of the geographical area.

Whilst appropriate OAPs are generally acceptable (arguably better) for patients and their families, the affect on Southern Health’s finances are the same.

³ PICU – Psychiatric Intensive Care Unit


Young beautiful woman in red dress looking to blue sea and fiery sunset

“‘Diva’ doctors threaten patient care.”¹

We have reported on the culture in the NHS previously here→ – and elsewhere.

New research commissioned by no less that the General Medical Council has identified five problematic subcultures amongst doctors in leadership roles:¹ 

Diva subcultures – powerful and successful professionals are not held to account for inappropriate behaviour. Left unchecked, divas become viewed as untouchable, and colleagues accommodate them and work around them.”

It was easy to find an image of a female diva but it is likely that are outnumbered easily by male divas. The other four subcultures are harder to illustrate! 

Shouting to a womanFactional subcultures – disagreement becomes endemic, and the team starts to organise itself around conflict. Those in dispute look for support and loyalty from colleagues, and staff may seek to avoid working with those on the ‘other side’.”



Patronage subcultures – arise around influential leaders who have social capital in the form of specialist knowledge, professional connections, high status, respect and access to resources.”


Embattled 4

Embattled subcultures – where resource has been inadequate, and unequal to demand, practitioners eventually become overwhelmed. They feel besieged by the unmet need they see in patients, and may show signs of chronic stress such as short temper, anxiety and burnout.


The silhouette of a lonely man

Insular subcultures – some units become isolated from the cultural mainstream of a larger organisation, resulting in professional practice or standards of care that deviate from what is expected. The isolation can be geographical or psychological.”

And of course these subcultures aren’t mutually exclusive. They may often co-exist alongside one another in the same organisation.¹ 

The full GMC Research Paper by Dr Suzanne Shale is available here→²

We believe that some of these features could be applied equally to many in NHS leadership roles, not just doctors.

I struggle to categorise Southern Health NHS Foundation Trust and may be able to identify features of all five subcultures. For now, from personal experience, we know that there are divas, who are not held to account for inappropriate behaviour and already consider themselves untouchable.

Would anyone like to suggest the subcultures that exist at Southern Health! If so please use the reply facility here→


¹ Health Service Journal: article by Annabelle Collins with comments by readers here→ . (Please note that the full article and comments are available by subscription only.)

² General Medical Council.