Mouth one way, belly ‘nother way


Old Australian Aboriginal description of a hypocrite:

Mouth one way, belly ‘nother way.

SH Notice2




Which brings us to a sign spotted at Southern Health NHS Foundation Trust’s HQ recently.







This from a Trust:

  • Whose Chair is accused of intimidating a patient’s representative at a Council of Governors meeting to the extent that the patient felt too intimidated to stay to ask an important question relating to his ‘care’. Read more→
  • Whose CEO is accused inter alia, of damaging patients’ health and discrimination under section 1 of the Disability Discrimination Act 1995 (as amended).

SH Notice1


How can Southern Health staff be expected change the way they think and act about mental health if their Chair and CEO set such a great example!


Dormitory Wards


Another of Southern Health’s dark secrets was revealed recently. It is 14th in a list of English mental health Trusts with highest number of dormitory wards and beds. Details→¹

Lunatic Asylums come to mind!


And, in respect of out of area placements (“OAPs”), where families have to travel afar to visit their loved ones, Southern Health NHS Foundation Trust was exposed recently as 7th on the list of mental health Trust having the highest number of inappropriate OAP’s². Whilst these are ‘inappropriate’, the definition of an OAP is:

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

This reflects the fact that, whereas inappropriate OAPs affect patients and their families, all OAPs have financial implications. Southern Health admitted: 

“The £1.1m deficit remains broadly the same as the previous month and
continues to be attributed mainly to out of area placements.”

It appears that Southern Health is massaging OAP figures by excluding contracted beds with Solent NHS Trust (6) and The Priory Southampton (10) from OAP figures because, “These beds are within our catchment area…” What part of HM Government’s ‘Out of area placements decision tree‘ does Southern Health directors not understand.

Whilst it is great for patents and families to have OAPs within Southern Health’s catchment area (especially those lucky enough to be admitted to The Priory), the affect on the Trust’s deficit remains. 

To adapt a well-known adage attributed to Benjamin Disraeli, in our opinion:

“Southern Health is an organised hypocrisy.”

And, for balance, patients can be guilty of hypocrisy too. I suspect the person who returned £250.00+ of medication to a local pharmacist claims the NHS is underfunded.

Wasted Scrips


In 2017-18, there were 11,619 community pharmacists in England.³

11, 619 x £250 = £2.9 million 



And that’s just one patient at one pharmacy. Apparently, a significant percentage arises from patients’ ticking every box on a Repeat Prescription form rather than tick just the items they need – and GPs do not cross-check diligently

A report by the Department of Health estimates that unused medicines cost the NHS around £300 million every year, with an estimated £110 million worth of medicine returned to pharmacies, £90 million worth of unused prescriptions being stored in homes and £50 million worth of medicines disposed of by Care Homes. 


¹ Source: Health Service Journal

² An inappropriate OAP: when a patient is treated out of their local area. [Media Office, NHS England and NHS Improvement – 26 June 2019]



Bored Meetings & Peter Drucker

Failed BusinessCRASH sat recently through two interminable Southern Health NHS Foundation Trust meetings – a Board Meeting on 14 May and a Council of Governors Meeting (“CoG”) on 28 May 2019: meetings which previously took place on the same day of the month. Result?

  • Fewer governors attend Board Meetings to judge how Non-executive Directors hold Executive Directors to account: that’s the Governors’ job! Just one there on 14 May.
  • Fewer members of the public attend both meetings to pose challenging questions.

This was entirely predictable: many governors and members of the public have full time jobs and other commitments. Most find it easier to dedicate one day a month to Southern Health rather than two three-quarter days (including travelling).

Also, details of the CoG were not published until it was too late to file advanced questions so only two members of the public attended. Even some staff at Trust HQ did not know about it until the day of the meeting.”



CRASH was one member of the public present at the CoG: the other (mentally unwell person) with a question to ask at the end, left half-way through feeling intimidated by the Chairman of Governors attempt to intimidate CRASH.

Naturally, the Lead Governor kept shtum, doing nothing to ‘protect’ the public.



The Japanese MD, Nagatomo-san, who pulled CRASH up the slippery ladder at Kawasaki without  much resistance!), was a disciple of legendary business guru Peter Drucker. Four of us got one of his books for Christmas – not an easy read so we can’t recall much!  A bottle of Faustino I Gran Reserva Rioja would have been preferred.

However, coincidentally last week, we came across a quote attributed to Drucker:

“Culture eats strategy for breakfast.”

Also the words were used and embellished in an article about the NHS in ‘The Journal of the Royal Society for Medicine’ headlined “Understanding organizational culture in reforming the National Health Service: it includes (amongst other robust statements) the following comment by a US hospital CEO about culture needed to transform the NHS:

“Culture eats strategy for breakfast, every day, every time”

The whole article by Prof. Huw T. O. Davies BA MA MSc PhD Hon MFPHM¹, published in November 2001, is compelling reading for those attempting to transform NHS Trusts. Read more here→

Yet Southern Health’s motto appears to be:

‘Strategies eat culture for breakfast, every day, every time.’

CRASH’s peers share our cynicism and came up with further variations :

“Strategies eat culture for breakfast meetings, every day, every time.” 

“Meetings eat everything, every day, every time.” 

Or (unrelated):

“We exist to talk about stuff, not to really do anything.”

To test the theory, CRASH carried out a word count on the papers of a random Southern Health Board Meeting using the search facility:

Strategy 61 plus strategies 5 = 66.

Culture 11 (no plural) plus cultural 2 = 13.

If  one analyses (or drills down as the NHS prefers to say) the results for culture, the figures are even more enlightening. Of the 13:

  •  3 are attributed to guests at the meeting.
  •  6 appear in the Trust’s risk assessments – because, “There is a risk that we fail to develop and maintain a culture….” or similar.
  • Only 4 are attributed to comments by Directors.

Most telling is this extract from the papers:

The Trust has liaised with other Trusts who have successfully implemented violence reduction initiatives and found that: setting targets for reduction does not work and promotes under reporting of incidents initiatives not supported by a quality improvement methodology will not be sustained in the long term as they do not embed and support cultural change.

This may seem a bit like gobbledegook but, if our interpretation is correct, it is somewhat bizarre that Southern Health, an organisation trying to introduce Total Quality Management, seems more interested in strategies than culture.

Low angle view of cricket umpire signalling six runs against blue sky


One could say of Southern Health NHS Foundation Trust:

“Strategy hits culture for six every day, every time




Southern Health claims to be improving community services yet the Basingstoke ‘Gazette‘ reports that it is scrapping the majority of drop-in clinics in Basingstoke for young Mums and babies!” Read more here→


We all know that babies are at the most vulnerable stage of their lives – so scrapping the majority of drop-in clinics really is a great idea, Nick, especially when the Trust  website and notepaper bear a logo claiming to put, “Patients & people first.” And the ‘Our Vision and Values‘ page of the website claims it as a core values.



A decision made by bean counters? Surely not.



Which gives us a great opportunity to close by paraphrasing Drucker again.



“Money eats patients for breakfast, every day, every time”



Back in the 1970/80s, little did we know that Drucker would be so useful 40 years’ later!When will Southern Health NHS Foundation Trust transform its culture?


¹ Honorary Member, Faculty of Public Health Medicine


The Secretary of State’s Desk

Woman businesswoman under stress missing her deadlines


“The rational response of an appointed NHS CEO is not necessarily to improve the long-term performance of the hospital, but instead to minimize the amount of bad news that ends up on the Secretary of State’s desk.”



This is just one conclusion to academic research,  ‘The Impact of CEOs in the Public Sector: Evidence from the English NHS‘ published by the Harvard Business School.

The paper, available here, authored by leading academics Dr Katharina Janke
(Lancaster University), Prof. Carol Propper (Imperial College & University of Bristol) and Prof. Raffaella Sadun (Harvard Business School) is supported by detailed, statistical analysis, which mere mortals would not pretend to understand.

The conclusions are enlightening and should be essential reading for the Secretary of State for Health & Social Care, his Junior Ministers and officials, along with the Boards of NHS Improvement and the Care Quality Commission.  Essentially:

“We find little evidence of CEOs being systematically able to change the performance of these organizations. We also do not find evidence that a change in CEO brings about an improvement (or even just a change) in performance.”

The paper proffers two possible explanations [abbreviated and paraphrased]:

“Lack of CEO effects is consistent with top managers chasing political goals, not policies that might improve hospital performance. The rational response of an appointed CEO is not always to improve long-term performance, but to minimize the bad news landing on the Secretary of State’s desk: this may explain why there is a CEO effect in remuneration, unassociated with observed performance, but with receiving public honours. The political nature of the NHS may lead to negative sorting (reluctance of high performers to seek CEO appointments). 

“Hospitals are large complex organizations, in which highly trained (and hard to monitor) individuals run separate, interconnected production processes. Top Management may find it difficult to engage in co-ordination and getting a large number of actors, who traditionally have not worked together, to work co-operatively. A possible interpretation of our finding is that the organizational inertia of a large hospital is often too strong for a CEO to impact performance.”

These conclusions are remarkably similar to expert (unscientific) analysis of Southern Health’s recent reply to a letter from Suella Braverman MP to the Secretary of State. A press release and Southern Health’s response are available here→.

The expert analysis is here→.  The similarities with the conclusions of the Harvard Business School paper are clear. For example [abbreviated and paraphrased]:

“I am also mindful that there is a political and PR exercise at play here.

“[Directors] have forgotten that the letter was addressed to the SoS. They address the points made as though it were directed to them as criticism and write what I feel is a very defensive letter. A better approach would have been to build on what was said and commit to what they could do with £5m to invest in the areas identified, or indeed suggest where the outcome could be improved by investing it differently. They simply don’t see this opportunity; they see this as a threat to their position and authority. Clear arrogance on their part I would suggest in that they know best. 

“They are dismissive about the points on GP training and the deployment of Medical Examiners essentially saying its someone else’s job to deal with those. Everyone is aware these are not Trust specific issues, indeed the work requires all parties to play their part and work as a team. Saying it’s for someone else to do is very much old school “pass the parcel” mentality which indicates there is much more to do to change the culture.

“Overall, the response doesn’t say a lot. It’s all aspirational. Very little is tangible in terms of specific results that can be expected to be seen by a specific time. 

“The first two pages of the [Trust’s]  reply are all spin and waffle. It tells us very little about what the customer can expect by way of improvements. It tells us there’s a new board, a focus on training staff in a QI methodology, a focus on improving patient and carer engagement, a new organisation structure and an improved culture. No detail as to what this will mean to the customer.  

Regarding the second explanation, we know Southern Health is a large complex organization, in which hard to monitor individuals who run separate, interconnected production processes. It is difficult to engage in co-ordination and getting a large number of staff , who traditionally did not work together, to work co-operatively. As we have said before, transforming an NHS Trust is more difficult than turning around an ocean liner.

When will the Secretary of State’s desk look like that of Russian Tsar Nicholas II in his office in Livadia Palace, Crimea – 4 family photo’s, 6 sheets of paper and a large tome?

figure of tsar Nicholas II in Livadia Palace


Triangle of Care

The combined hands, are forming a triangle

The Triangle of Care is not a difficult concept – it’s just common sense. Yet how many Mental Health & Learning Disability Consultants and other clinicians ignore it?

We reported the Inquest into Ellie Brabant’s death just three months ago. Yet this month, we attended the Inquest into Maria (‘Joey’) Duarte’s death. She died at the same Southern Health NHS Foundation Trust unit (Antelope House) just 2.5 months after Ellie.

Ellie and Joey had two things in common – extremely supportive families – and the same Consultant Psychiatrist, Dr Obed BekoeYet were the families involved in their care?

NO! Dr Bekoe admitted he had not engaged with Joey’s family because he felt she had capacity and she had not requested it.

Dr Bekoe: As a Consultant Psychiatrist, an Expert Witness, an RCPsych Examiner, an Educational Supervisor and a Medical Appraiser, exactly what part of the Triangle of Care do you not understand?

Patients don’t have to ask about family engagement: they should be offered it. Capacity in a patient with suicidal thoughts should not be assumed.

Best practice is clear and unequivocal:

Triangle of Care 6


“In line with good practice, practitioners should routinely confirm with people whether and how they wish their family and friends to be involved in their care generally, and when looking at information sharing and risk in particular.”¹



In short, a patient’s capacity is irrelevant – clinicians should discuss family engagement with patients routinely – not wait for patients to ask. Even in respect of capacity, good practice suggests:

“If a person is at imminent risk of suicide there may well be sufficient doubts about their mental capacity at that time.”¹

Is this not common sense too? In CRASH’s opinion, for example, there must be doubts about the capacity of anyone, who sits on a railway bridge for five hours threatening to throw himself off – much less a person known to be mentally unwell. Yet, another Southern Health Consultant Psychiatrist thinks not. 

¹’The Consensus Statement on Information Sharing

Unrelated directly to ‘The Triangle of Care’, the Department of Health, Royal College of Psychiatrists and others issued a ‘Consensus Statement‘ in January 2014 as part of the suicide prevention strategy for England. It aimed (inter alia) to improve information and support for families concerned about a relative, who may be at risk of suicide.

The General Medical Council, Nursing and Midwifery Council and Health and Care Professions Council confirmed that the advice and policies set out in the Statement are consistent with their guidance on consent. The Information Commissioner’s Office confirmed that it is consistent with the Data Sharing Code of Practice. Read more→Conceptual mental health or positive thinking triangle arrow word cloud isolated background. Collage of optimism, psychology, mind healthcare, thinking, attitude balance or motivation text

So why, five years later, are some Members of the Royal College of Psychiatrists not compliant with good practice in this respect and why did Southern Health only learn about it in 2019? 



There were multiple other similarities between Ellie and Joey’s deaths, for example:

  • The same Responsible Clinician, Dr Obed Bekoe.
  • Total failure to work with a very supportive family.
  • Identical ligature point – top of a door.
  • Similar ligatures – clothes.
  • Observations, when expressing suicidal thoughts, too infrequent and carried out by junior staff.
  • Allowed leave from Antelope House despite concerns about their well-being. (Joey was a voluntary patient but could have been sectioned.)
  • Both passed like parcels between various Southern Health Teams and multiple Responsible Clinicians without proper handovers/communication/care plans/risk assessments.
  • Questions about medication.
  • Failure on at least one occasion to record suicidal thoughts.

There were a couple of common problems indentified at the Inquest:

  • Junior staff blamed rather than senior staff taking personal responsibility (with the honourable exception of the male senior nurse, who gave evidence in person).
  • A page from shift handover notes missing from Coroner’s bundle – revealed by the senior nurse. Yet again Southern Health lacks diligence in preparing Inquest documentation … and yet again the moment passes without any consequences for them. A deliberate act or simply incompetence?

In short, total failure in clinical management, family engagement and Inquest preparation.

side-way-smiley-face-emoji (rediced) 2

On a positive note, Southern Health officers and staff  were soberly dressed and conducted themselves appropriately at Joey’s Inquest. There was no laughing and joking as witnessed at Ellie’s Inquest.


Lynne Hunt, Chair of South Health’s Board of Directors, said:

Pic by Samantha Cook Photography, 30th March 2016. Portraits taken of board members at Dorset HealthCare University NHS Foundation Trust, Sentinel House, 4-6 Nuffield Road, Poole BH17 0RB.

Our own investigations and the coroner’s conclusions revealed missed opportunities. Joey’s death has led to meaningful and ongoing changes to make Antelope House, and indeed all our whole trust, a safer place.”

All good stuff (and some improvements were not ‘quick fixes’) but Joey’s family could well ask:

“What steps were taken to implement the simpler improvements, which were clearly required immediately after Ellie Brabant’s death?

“The Board did not report any of the clinicians involved in Ellie’s death to their regulators? Will the Trust report those involved in both deaths to regulators or – failing that – will they be disciplined internally, retrained and supervised?

Elsewhere, Greater Manchester Mental Health NHS Foundation Trust received a second gold star for its commitment to the national Triangle of Care initiative. (Alarmingly at the time, only one of four mental health trusts in the country to do so.)

West London Mental Health NHS Trust committed to putting it in place during 2018.

And finally, on the website of Kent and Medway NHS and Social Care Partnership Trust:

“The Triangle of Care guide was launched in July 2010 by The Princess Royal Trust for Carers (now Carers Trust) and the National Mental Health Development Unit to highlight the need for better involvement of carers and families in the care planning and treatment of people with mental ill health.”

To paraphrase the Princess Royal herself, after nine naffing years the Triangle of Care is still not in place at Southern Health or nationally and after naffing five years, Consultants are not compliant with good practice set out in the Consensus Statement.   

And here’s a couple of images found on the website of Avon & Wiltshire Mental Health NHS Partnership NHS Trust – awarded a second star in 2015:Triangle of Care 2




Triangle of Care 3












When will Southern Health NHS Foundation Trust achieve similar recognition?

Rest Day

Funny golden retriever labrador puppyÊlying stretched at poolside

Madcap 2019 to date dealing with Southern Health, helping complainants and holding the Board to account, so much so that writing a blog post constitutes a rest day!

So, we thought it should be a lazy day too – simply re-blogging others’ efforts. But before we do, the latest ‘news’ from Southern Health.


SuellaHoC(2) Reduced

14 February 2019: excellent MP, Suella Braverman (née Fernandes) and four fellow Hampshire MPs¹ co-sign a letter to the Secretary of State for Health & Social Care, Matt Hancock MP, expressing continuing concern about Southern Health. She outlined ways in which she felt the Secretary of State could provide more support. Read more here→.


Southern Health’s reply (available here) is viewed as all talk and no action: Suella’s letter backs fully the main thrust of a paper put to the Board on 1st February 2018 and a Position Statement in November 2018, both by well-informed experts by experience.

Considered opinion by one of these experts is that Southern Health’s Chair and CEO have completely overlooked that Suella addressed the Secretary of State. They address her points as if directed at them as criticism and respond with a very defensive letter. A more positive approach would have been to build on what was said; commit to what they could do with £5m to invest in the areas identified; or indeed suggest where the outcome could be improved by investing it differently. Another opportunity missed!

They simply don’t it as an opportunity, they see it as a threat to their position and authority. Clear arrogance on their part – they know best.

British Association of Social Work Conference 

“Safeguarding and human rights: what do families need from social work? What do we need? Easy peas: thoughtfulness, understanding, knowledge, integrity, action, transparency and honesty.” [Dr Sara Ryan]

And we need a dose of this in NHS mental health and learning disability services too².



The Minister of State for Health & Social Care, Caroline Dinenage MP (named here) is one of the Hampshire MPs, who signed Suella Braverman’s letter to the Secretary of State.


Has Matt Hancock based his new NHS IT plans on “Yes Minister”?

Computer Wiring


Question? What would Sir Humphrey do, having spent over £11.4 billion on the notorious National Programme for IT (NPfIT), described as a major ‘push’ to improve NHS IT systems, only to dismantle it as one of the mostly costly and troubled projects in public sector IT history? [Analysis by University of Cambridge academics here.]

© 2016 Tads India


Answer? Create a new departmental unit (NHSX); require up to £13bn in IT investment over 5 years; employ more civil servants; give different job titles to existing officials; and/or create new job titles at higher pay grades! YES MINISTER!


Somebody using a Mencap supported living service wants to take Mencap to Court using Mencap’s legal support service. Conflict of interest and PR Campaign? Interesting and thought-provoking comment and potential solution here→.

SEND (Special Educational Needs and Disabilities)

The SEND Plan assists children and young people’s ability to learn. Typically, it helps those up to the age of 25 with difficulties, including:

  • Behaviour or ability to socialise, such as struggling to make friends, for example those with autism or Aspergers.
  • Reading and writing, for example those with dyslexia.
  • Ability to understand things, for example those with moderate learning difficulties.
  • Concentration levels, for example those with ADHD.

Naturally, children with physical disabilities are included too.

However, the SEND law is alleged to have been poorly understood and inadequately implemented in schools. Unsurprising perhaps when the SEND Code of Practice runs to 292 pages. Apparently, schools often sanitise plans, for example by replacing ’cause for concern’ with ‘barrier to learning’… read more. Just as the NHS uses ‘learning opportunity’ to describe a ‘cock-up’! The old duck-billed platitudes again!


¹ Caroline Dinenage, Sir Desmond Swayne, Maria Miller and Ranil Jayawardena.

² More to come on ‘integrity’ in the NHS.