“The Dark Side of the NHS”

Socks Eyes

CRASH has experienced serious IT issues. Some suggested that we might have been ‘got at’ but we found no evidence of this. It necessitated a change to our email address

The Pascoe Investigation re-started dramatically on 6 April 2021. Nick Ralls¹, an NHS accredited hypnotherapist, whose son has been a service user of Southern Health NHS Foundation Trust and its predecessor body for over 20 years, alleged that his experience of, “Engagement” with the Trust’s Board had, “Got worse over time“. He could not see, “Any improvement” in the complaints process, adding:

“I don’t see a cultural change…. It seems to be more problematic as time goes on, the way the complaints are handled.”

A full report of Nick’s evidence is on the BBC website here→. Others share his view.

Next were two witnesses relatively supportive of Southern Health (unsurprisingly ‘NHS-lifers’). The Chair of Healthwatch Hampshire, Anne Smith, appeared ill-informed. Dr Vaughan Lewis, S.E. Regional Medical Director, NHS England, displayed little knowledge of Quality Improvement. He admitted lack of expertise in mental health and learning difficulties and that these subjects are normally addressed by staff 1/2 steps below him. Where is the parity of esteem – enshrined in law by the Health and Social Care Act 2012?

Bizarrly, we heard from retired Judges – His Honour Judge Neil Butter CBE (rtd. 2001) and His Honour Judge Keith Cutler CBE (rtd. 2021). The former asserted that retired judges should not chair serious incident investigations (“Judges do not do empathy“) whilst the latter said the opposite because judges have (“Empty brains“). In short, they cancelled eachother out – Judges would require ‘expert’ advisors too, thereby racking up costs. 

We then heard three truly independent, authoritative witnesses, whose evidence was extensive, compelling and very well-informed. 

Dr Bill Kirkup CBE


A fearless veteran of many investigations Dr Kirkup led inquiries into Morecambe Bay maternity services and Jimmy Savile’s involvement at Broadmoor. He was a Panel Member of the inquiry into the deaths at Gosport War Memorial Hospital.


Dr Kirkup asserted that Trusts need to address five issues in investigating incidents: 

  1. They should not adopt a defensive mindset or challenge findings made against it. 
  2. Effective leadership: especially when things go wrong. Public must trust the leaders.
  3. Breakdown in clinical relationships – between those with different clinical backgrounds. Once embedded, professional jealousy is hard to identify.
  4. Clinicians do not own up when things go wrong, especially if someone has died. They look for reasons to deny liability. There is a subculture of invincibility. 
  5. Disconnect between senior leadership and front-line workers, which lead to ineffective clinical governance.

In rating complaints handling, Dr Kirkup rated some Trusts as very good; 70% adequate; and 10% incomprehensibly bad. 10% do not learn from incidents. He referred to the ‘We can’t make a mistake’ culture still prevalent amongst doctors and believes that overcoming the, ‘Subculture of impossible expectations’ must begin with doctors’ training. However, the General Medical Council says it has no room on the syllabus.

When asked how the 10% could be identified and improved, he referred inter alia to the following requirements. 

50027334 - learn and lead business concept


  • The Chief Executive Officer (“CEO”) and Directors must be closely engaged in patient safety issues and complaints.


  • Many spend too long looking at high level figures, which do not tell the whole story.
  • Many do not check learning such as by talking to people, including service users. 
  • Hierarchical systems and ineffective teamworking are a feature of poor leadership.
  • Boards often do not have the ability to recognise what’s go on – directors should go out talk and visit places. Bad ones shut themselves behind a key card!
  • Good leaders admit when they need professional help; others fool themselves and don’t tell anyone.
  • There must be accountability for change: without improvement, the leaders must go.
  • Current assessment of leadership by regulators is not working as well as it should.
  • Changing deep-seated attitudes and culture depends on leadership. 
  • Does it need a change of leadership to change culture? Very difficult to change culture unless the current leadership admits to the Trust’s errors.
  • A change in culture often needs a change in leadership. 
  • Only service users, carers and families can attest to changing culture.

Duty of Candour

  • Just be open and honest – there should be no need for a legal duty.
  • There must be full, immediate disclosure of evidence – families and patients must be involved throughout to avoid loss of trust. Those who recognise most incidents often the safest. If the process is not inclusive things can be missed.
  • Subculture of impossible expectations and clinical denial – “We can not make a mistake culture” still prevalent.  
  • Needs a process and audits to ensure learning is implemented. 
  • Clinicians should have proper meetings with customers, not ‘edge of the bed’ talks; admit to their errors; and welcome customer involvement. 

Triangle of Care 6Customer Involvement 

Lack of communication with families stems from clinicians not accepting that things go wrong: the reach for reputational management starts at clinical level. They do not want to sit down with people and listen.


Complaints & Investigations

  • Response to complaints is not good, often dismissive/hostile. ‘Get rid of them a.s.a.p.’ – they are not linked to clinical governance and can become confrontational.
  • The gold standard is that complaining should be easy. He emphasised progress made in the commercial sector in this respect.  
  • People should not be looking at their own incidents – will not get best learning.
  • Independence of investigators must be proportional – they can be part of same Trust but not the same team. In more complex serious incidents, it is wholly wrong that Trust investigates itself; it must be wholly independent.
  • Investigations should not be led by clinicians – they are not objective. Bishop James Jones is a good example of an expert in leading investigations. Educational background is immaterial – they need to understand the process. 
  • Families should be involved throughout: meetings should be informal with  constructive dialogue, avoiding Trusts being told by lawyers not to answer questions.
  • When families require legal assistance, it should be provided.
  • There is no criteria for the commissioning of an independent inquiry – should include deaths or systemic failings. Dr Kirkup found a death where a simple check list was produced – 9 months later, it happened again.
  • Must involve relatives and/or customers in investigations. Investigators should be open with people, not treat them as witnesses. 

Medical Records

  • Medical records often show events as they were ‘thought to happen’; they are too ‘clinical.’ This needs to be remedied. 

48375735 - learning never ends message on the card shown by a man

Learning & Action Plans

  • Investigations should lead to firm action plans. There can be a good process, but learning is then ignored, especially in dysfunctional Trusts.


  • Needs a process to ensure that learning is implemented. For example, quality committees.
  • Customer involvement in improvement and repairing ‘damage’ is essential.
  • There should be an audit of action plan implementation. Directors are accountable, and Regulators should check. 
  • CCGs should be responsible for checking action plan implementation but this rarely happens. 

Mysteriously, a Panel Member asked Dr Kirkup if his experience clouded his judgement of the NHS overall. Why does a Panel (whose own independence has been questioned) challenge a truly independent witness?

Bill Gates Adage

Dr Kirkup was asked how to treat families, who are not happy with the outcome of an investigation, and how to support them long-term.

He emphasised that the first time is the best chance of getting it right, adding that this often doesn’t happen and the longer it goes on the worse it gets.

Families are best experts on their own case.

Read more by leading expert Anita Toth¹→


Dr Kirkup sees a role for mediators – not in investigations but in mending fences. However, both parties should be willing to engage in the process with an open mind. He emphasised that they should be run by an independent professional mediator – not a clinician. At Morecambe Bay, he thought it was successful in certain cases after the investigation.

Dr Kirkup believes that the role of Medical Examiner is vital – but they only should be involved as a ‘long-stop’ and should not be an employee of the Trust. 

The best compliments heard about Dr Kirkup’s evidence are expressions of regret that he was not Chair of this Panel. However, if the Panel assesses Southern Health’s leadership and service users’ evidence against Dr Kirkup’s observations, its report will be damming.

50349497 - boy wearing a dunce hat

Clearly, the current leadership at Southern Health NHS Foundation Trust has shown no wish to engage with its most unhappy customers – the bereaved families.

It refuses to use them as any source of learning.

Indeed, it has done exactly the opposite!



Dr Kirkup was followed by Dr Josephine Ocloo (Senior Researcher and Health Foundation Improvement Science Fellow at King’s College, London) and Keith Conradi (Chief Investigator at Healthcare Safety Investigations Branch).

Their evidence is so important that it warrants a separate report. For now, we must credit Jospehine for her description of historical cases as, “The dark side of the NHS.”


¹ “When you have a lot of unhappy customers demanding limited time and limited resources, the financial cost can be big—from hundreds to hundreds of thousands of dollars. The faster you can reduce the number of unhappy customers you have, the better it is for your business.” [Anita Toth, ‘Bill Gates Says Unhappy Customers Are Good for Your Business. Here’s why’, first published 22 October 2020 in ‘Entrepreneur Europe‘.]

Cloud Cuckoo Land?

Young man keeping mind conscious.Another weird week (ending 19 March) in the ‘not-so independent’ Public Investigation into Southern Health NHS Foundation Trust: a complete absence of service user/family/carer witnesses and no robust challenges by Panel Members.

Terms of Reference (“TORs”):

Before asking questions, ‘independent’ Panel Member, Dr Durkin asserted that the Panel’s role was to look at the current and future – not the past. This is an alarming departure from the TORs, which state that the Panel would consider:

“The extent to which the Trust has implemented recommendations from previous reviews and investigations and where further improvements can be made.” 

“The supervision structure that has been in place since 2011 by the Clinical
Commissioning Group [“WHCCG”] … and how it has been exercised towards the Trust in relation to complaints and investigations, and of any planned changes in the light of public concerns.”

The key previous inquiry was the Mazars Review [January 2016]. Dr Durkin, did you not notice that 2011 and 2016 are not the current or the future! Could your refusal to address the past relate to your role as NHS National Director of Patient Safety [2012- 2017]? Surely not!

There are countless adages on this subject too – from the 14th to the 21st century:

“The past resembles gthe future more than one drop of water resembles another.” Ibn Khaldun [1332-1406].

“In order to plan your future wisely, it is necessary that you understand and appreciate your past.” Jo Coudert [1923-2015].


Dr Katrina Webster, Clinical Lead, Mental Health & Learning Disability, W. Hampshire CCG.

Thumbs downEmployed by WHCCG since 2011 so ideal for the Panel to question about the supervision structure in place since 2011 as per the TORs. They failed to do so after Dr Durkin’s intervention.

She made several questionable claims: for example the Trust engaging more with families and service users; an improvement plan in place since 2016; and that the Trust had acheived its targets on care plan standards. No doubt unwittingly, she identified the difference between policies/plans and outcomes. She went on to say that 80% of carers didn’t know about care plans and others didn’t think they were worth the paper they are written on – yet the Trust is allegedly meeting its targets!

She had never seen some reports; could not answer key questions; and has no data to show discharge planning from secondary care had improved – she just ‘believed’ it. CRASH’s Freedom of Information Requests suggest that s.117 after-care¹ is a shambles. 

She admitted that Southern Health is not as good as other Trusts on communicating with patients, families and carers, “Until you find the right people, which is difficult.”

Steven Hales, Deputy Chair/Lay Member Working in Partnership Committee (“WIP“)

Thumbs down

Mr Pascoe started by emphasising that the Panel was especially interested in improvements in the last year, i.e. forget the TORs again!

Steven made some surprising assertions, which were at best exaggerated and at worst inconsistent with reality, for example about service user/family/carer involvement.

He engaged in his fair share of service user/family/carer blame, claiming that some complainants will never be satisfied and the priority should be how complainants are dealt with now. Again, forget the past! He claimed it was a communication problem to reach out to those who really hurt to convince them that things are different. He talked of advertising, public relations and leaflets. This is pure spin.

The answer is easy. TALK TO THOSE WHO HURT (the Trust has contact details) and remember, THE CUSTOMERS IS ALWAYS RIGHT. 

Most customers, who are now hurting, could have been satisfied if the post-2017 regime had not brought to an end co-operation with the Forum for Justice and Accountability at Southern Health (“the Forum”) and later with the breaved family group (set up by Alan Yates as Interim Chair). Initially, we were consulted and decribed as ‘critical friends’ of the Trust.

Indeed the Pascoe Investigation might have been avoided if, after Alan Yates left, the new regime had not brutally ended co-operation with the bereaved family group and ‘kicked the Forum into touch’. Could this be because the Chair and both CEOs are fearful of the members’ combined expertise and their robustness in challenging the Board. Surely not!

Notably, Stephen said one governor normally attends WIP meetings. ONLY ONE? 

He claimed Southern Health is not the same as it used to be and that it is safer now. He would not hesitate to refer his friends and families to the Trust. All talk and no evidence.

Amelia Abbott, Carers Strategy Project Officer/Triangle of Care Project Lead

Thumbs logo - greenJoining 9 months ago, Amelia made a refreshing change – a Southern Health official with genuine enthusiasm for her role; keen to make improvements; and with an impressive grasp of the Triangle of Care (“TOC”).

She was unafraid to expose the Trust’s continuing shortcomings. For example, the Forum have been recommending the TOC since 2016, and despite the Trust’s deadly failings in family liason exposed at two Inquests just 3 months apart, Amelia admitted that the Trust hasn’t achieved Stage 1 accreditation 5 years later. The Forum could make significant contributions to assist – if only we were allowed to do so. For example:

India realistic waving flag vector illustration. National countrAt a Board Meeting on 4 December 2018, CRASH suggsted the Trust should adopt two sections from the Indian Mental Health Act 2017 (“IMHA”) as best practice. Minuted here→

We contacted the two experts named by the Trust, Prof. Dimash Bhugra and Prof. Sir Simon Wessely. They agreed that section 98 of the IMHA could be used in UK as ‘best practice’ without changing UK law:

“S.98 (1): When a PMI² is discharged into the community or to a different mental health unit or a new psychiatrist takes over, the existing psychiatrist must consult the PMI, the nominated representative and the relevant family member or carer. (2): The existing psychiatrist will, in consultation with the persons referred to in s.98(1), ensure a plan is developed as to how treatment of services are to be provided.” 

We also found useful guidance in the World Health Organisation Rule Book.

Simples! TOC and Care Planning improved in one go – if the policy is strictly applied. Yet has this been implemented? We doubt it – we continue to see failings in care when inpatients are discharged or transferred between hospitals and/or Consultants.

Amelia made useful observations on TOC training. At first, she saw an average of only 6 staff on courses but this is increasing: her next course is full. Even more enlightening (if unsurprising) is that she typically saw nurses and allied health professionals – but only occasionally Consultants and doctors. She agreed that better data is needed on this.

Beth Ford, Service User Involvement Facilitator

Thumbs down

Beth is to be commended for disclosing her autism and mental ill-health but, having asserted that the Panel (as a result of her autism) would only hear the truth, she made two seriously misleading statements, perhaps unwittingly.

  • She claimed there were no Out-of-Area Placements. If this were true, why would Southern Health invest £3.3m on two new mental health wards with a total bed capacity of 28. The target opening date is Summer 2021. One ward is specifically to “Provide  mental health support to women  in a bid to prevent the need for treatment outside Hampshire.” Marchood Priory is still receiving NHS-funded patients too. 
  • She denied that the Trust is responsible for 111 services – a half-truth: Dr Broughton set up a specialist 111 team manned by Southern Health staff but based at the 111 call centre. We know this after supporting a service user in a complaint about 111.

  She made a number of other dubious assertions. For example:

  • To talk with as many service users, carers, families as possible to gather feedback. 
  • Before 2019 (when she joined) she would not be treated by the Trust. Now she would. To misquote Mandy Rice-Davies, “Well, she would say that, wouldn’t she?”
  • There has been a major culture shift at Southern Health since she joined.

However, most alarming revelation was the description of her day-to-day activities. She alleged to have: all-points access to Trust units; unsupervised access to patients and their records; free reign to upbraid Southern Health’s clinical staff and others; and authority to resolve complaints on the spot. She also claims to barge into Directors’ offices on a whim and admits to occasional use of inappropriate language in doing so. 

super cop from the future, cyberpunk. Police

Beth – ‘Robo Cop‘ of Southern Health?

However, the NHS includes as common signs of autism – finding it hard to understand what others are thinking or feeling and seeming blunt, rude or not interested in others without meaning to.

Indeed, we believe there are serious risks in an autistic person carrying out this role unsupervised – including a risk to the person doing so. Indeed, is this not a role for Board and Divisional Directors?    

Two observers could not believe their ears – despite their combined business experience, including Quality Improvement, they had never seen such a bizarre management structure. 

Scary EmogiEven allowing for her disability, if Southern Health’s Board truly believes this attitude and modus operandi will encourage service users, families, carers and staff to speak up truthfully, they are sadly mistaken – living in Cloud Cuckoo Land one might say

Again, all Beth’s evidence related to the alleged improvements since 2019. She did say, without a hint of irony, that she felt some NHS staff were intimidating people! She made other interesting points, which require further research, relating for example to complaints handling, use of generic email addresses and unpaid service user volunteers.


Two ex-Public Governors summed up Southern Health’s management structure succinctly.

“All the plans are bolt-ons – find a problem and form another committee with little oversight. You can’t buy a Land Rover and turn it into a F1 racng car by buying and bolting on extras.”🙁

“I’m getting the hang of their modus operandi. Let one CEO move on, and blame him for everything if convenient! (They didn’t seem as bold to blame that woman [Katrina Pecy] when she led the Trust!) I’m quite perturbed at Lynne, because [redacted for legal reasons]. I believe a lot is being done to undo the good work of public involvement and holding to account during these Covid times. I would not be surprised that there will be lots of scandals afterwards.” 🙁

In short, transformation of Southern Health is a long, long and very dusty ol’ road.   

Badwater road Death Valley National Park CaliforniaWith apologies to Jerry Jeff Walker


¹ Section 117 of The Mental Health Act 1983 (as amended) makes Local Authority Social Services and CCGs entirely responsible for aftercare.

² PMI – patient with mental illness.

³ Cloud Cuckoo Land: a state of absurdly over-optimistic fantasy. As in, “Anyone who believes that these plans will be effective is living in cloud cuckoo land”.

(opens in 


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 –  a.scott@pumpcourtchambers.com 


¹ Sideshow | Definition of Sideshow at Dictionary.com

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!!!”