“Patronising disposition of unaccountable power!”

50132944_s reduced twice

In commenting on his Panel’s report on deaths at Gosport War Memorial Hospital, The Right Reverend James Jones KBE likened it to the title of his Report on Hillsborough, which  concerned the death of 96 Liverpool football fans at the 1989 FA Cup Semifinal:


Departmental sign at Gosport War Memorial Hospital, Gosport, Hampshire UK. Image shot 2009. Exact date unknown.His Panel concluded that the lives of over 450 people at Gosport War Memorial Hospital were shortened owing to an, “Institutionalised regime” of prescribing and administering opioids without medical justification.



Gosport War Memorial Hospital in now managed – you guessed it – by Southern Health, which issued a public statement containing the usual duck-billed platitudes¹. Read its statement here→ and the Panel’s Report here→

So we have:

So, from babies undergoing heart surgery (Bristol) to adults with physical ill-health (Mid Staffs and Gosport) to dying patients (Liverpool and elsewhere) to maternity and neonatal services (Morecombe Bay) to those with mental health issues and learning disabilities (Southern Health), it appears that all are at risk of similar patterns of behaviour by NHS clinicians and executives, as described in these Inquiries.

In his report on the high mortality rate of babies undergoing heart surgery at Bristol Royal Infirmary, Sir Ian Kennedy QC referred to:

“‘An old boy’s culture’ among doctors, a lax approach to safety, secrecy about doctors’ performance and a lack of monitoring by management [and] an arrogance born of indifference [our emphasis].”

And in the Liverpool Care Pathway review, Baroness Neuberger (and others) wrote:

“It is clear to us [from verbal and written evidence] that there have been repeated instances of patients dying on the LCP being treated with less than the respect that they deserve. It seems likely that similar poor practice may have taken place in the case of patients with no close relatives, carers or advocates to complain, or where families have not felt able or qualified to question what has taken place. This leads us to suspect this is a familiar pattern, particularly, but not exclusively, in acute hospitals.

“Reports of poor treatment in acute hospitals at night and weekends – uncaring, rushed, and ignorant – abound [our emphasis].”

Patronising, unaccountable power, institutional regime, ‘old boy’s culture’, lax safety, secrecy, lack of monitoring, arrogance, indifference, disrespect, poor practice, uncaring, rushed and ignorant? Surely not!

Headless Chicken - reduced


And when ‘found out’, NHS executives run around like headless chickens to cover their backs rather than adopt recognised Crisis Management techniques and learn.



business-people-silhouette-clipart-panda-free-clipart-images-DZ4NzG-clipart reducedAnd, as soon as the crisis appears to have been resolved, let’s return to square one.

¹ More on duck billed platitudes here→


Polishing a turd

Turd V2

CRASH prefers to avoid the vernacular but, if, “Polishing a turd“¹ is OK for UK Cabinet Meetings, it’s OK here. Also, we found it had already been used about Southern Health [Sloven] – on December 5, 2015 at 7:16 pm – by ‘thelovelywibblywobblyoldladyon Dr Ryan’s blog (here) in the run up to publication of the Mazars Review:

“It must by now be plain and obvious to all (including Sloven) that the report is so damning, Sloven are attempting to polish a turd before the report is (finally) released.”

Unfortunately, after a brief clean up by second Interim Chairman, the excellent Alan Yates, it’s time to get the shovels out again. Southern Health has revived its slippery complaints handling (and other) tactics. For example:

  • Disclosing data without third party consent, when it suits the Trust to do so and especially when the data is grossly inaccurate.
  • Withholding third party data, on which consent has been granted, when it suits the Trust to do so.
  • Refusing to disclose data relevant to a complaint.
  • Appointing a senior official to liaise with a complainant and supply evidence, rather than the Complaints Manager and her staff.
  • Deny complainants equal access to evidence, especially transcripts of interviews with those accused of misconduct.
  • When this skulduggery is identified, instruct the investigator to publish a draft report and set an unreasonably short deadline for the complainant to comment.
  • Recommend an advocacy organisation, which is, “Rationing” services and, “Driving towards getting people ‘self-helping'”, owing to lack of funding – ideal [for the Trust]in dealing with complaints from mental health and/or learning disability patients!
  • Offer help and advice from Advocates who are not permitted to advise.
  • Appoint an official, who is explicitly engaged in an incident, to handle the resulting complaint and check the draft investigation report for factual accuracy!
  • Attempt to trick complainants by quoting GDPR³ and The Data Protection Act 2018 as a defence to data breaches when the breach occurred under The Data Protection Act 1998, i.e. before the new legislation came into force³.  

Probably more bullet points to follow!

Southern Health has not responded to a request for comment.

And the Chief Executive of an Advocacy Service commented recently, in writing:

“It is clear from my conversations with [advocate] that [Southern Health]  managers have put their own spin on the recorded communications that date back to 2016 and these have been embellished to their advantage, which is highly unprofessional.”

36657660 - cartoon of businesswoman, the dilemma of a whistle blower.


And what of Southern Health’s whistle-blowing policy, in which CRASH was consulted at the instigation of Alan Yates.



We believe Southern Health’s Freedom to Speak-up Guardian is a decent and professional individual but cannot be expected to be available 24/7. So the Trust decides Complaints Team members should act as back-up contact for whistle-blowers, despite that they report to an Associate Director, who does not believe complaints staff should take whistle-blowing disclosures and has already identified one whistle-blower.

94237238 - girl collecting horse excrement in shovel at stableyard


It’s time to get the shovel out again Alan.

Next [and related] post: “Patronising disposition of unaccountable power!”²




Turd Polish


¹ Trying to make something hopelessly weak and unattractive appear strong and appealing. An impossible process that usually results in a larger, uglier turd [Urban Dictionary]. Buy your own sewage polishing filter pads from Amazon here→!

And proof it can be done→

²  Title of Hillsborough Report by Bishop James Jones.

³  General Data Protection Regulations (“GDPR”). The Data Protection Act 2018 received Royal Assent on 23 May 2018 in advance of the application of GDPR on 25 May 2018.

LeDeR and Leaders

The LeDeR Report was published on Friday, 4 May: three years of Bristol University’s project reviewing the premature deaths of learning disabled people. Coincidentally, on 9 May, Southern Health presented itsFuture plans to develop our Secure Forensic Mental Health and Learning Disabilities Services.

The LeDeR Report

There is plenty of blog commentary on the LeDeR Report by Dr Sara Ryan, Mark Neary, Mark Brown, two posts from Professor Chris Hatton here and here. Also an opinion piece by Ian Birrell here. All worth reading.

Key issues (Dr Sara Ryan)
1. The findings of the report (shameful).
2. The underfunding of the work (shameful).
3. The attempts to bury the report (shameful).

Those referred to above have far more knowledge of learning disabilities than CRASH. Our education has come from Sara and the preventable death of her beloved son Connor; Jane and Ian Hartley, whose son Edward had profound learning disabilities and died aged 18 in May 2014 following complications from an epileptic seizure; and others who lost loved ones whilst in the ‘care’ of Southern Health.  Our eyes have been opened, not only to the care (or lack of it) of persons with LD by the State but also of the valuable contribution they can make to society.

Future plans to develop our Secure Forensic Mental Health and Learning Disabilities Services [Southern Health]

On Wednesday, 9 May at a public meeting, Southern Health presented its future plans for secure forensic adolescent mental health services and for adults with Learning Difficulties. A summary of the strategy is available here→; a full colour presentation here→;  and plans for the Proposed New Learning Disabilities Residential Unit on the Rufus Lodge site here→.

Credit, where credit is due – the need for more beds for forensic psychiatric adolescents and improved LD facilities is ‘a given’. The architectural plans are very impressive but perhaps the most poignant comment came from a Governor:

“I am sceptical of new buildings for projects, its the mindset of the people that matters most.”

The adolescent forensic services should be OK under Dr Mayura Desphande – an excellent and empathetic Consultant – if she can get the staff. Our concerns are:

  • However impressive the architectural plans,  in the end it’s the expertise and empathy of management and staff that matters.
  • Southern Health already has  staff recruitment problems for hospitals on the Tatchbury site, owing to its remoteness and recent history: when the building work is finished, they will need more specialist staff.
  • The temporary but lengthy transfer of adults with learning disabilities from a reasonably pleasant environment at Woodhaven to Ravenswood – only one step down Special Psychiatric Hospitals, such as Broadmoor. Unless he has been moved since 2015, Ravenswood houses infamous hack-saw murderer Daniel Rosenthal¹.
  • Ravenswood also is an old building.
  • The plans also rely on strengthening the Community Mental Health Teams.

The Trust says that patients, family and carers and staff have all been informed but were they told the true nature of Ravenswood or given the opportunity to see it? 

One disappointment – we asked the lead officer for the project if he had approached Dr Sara Ryan for her comments on the LD strategy and facilities. He answered : “I know of her.” We suspected what he meant – “No, I haven’t approached her“: we were right.

With the exception of the failure to approach Sara, at least this is a sign of the good intentions of the new regime, but, as they say, ‘the proof of the pudding….’²

If anyone has comments about this strategy can be left here or you can email the Trust’s Chairman, Lynne Hunt, or the CEO, Dr Nick Broughton.

Blue Star Minute

Bluestar here’s a heartwarming story about Bluestar bus driver, Mike Rogers, who helped an autistic boy get home after he boarded the wrong bus.  He has other learning difficulties, including attention deficit hyperactivity disorder.

Gold Star MinuteAnd a Gold Star for Mike


¹ Daniel Rosenthal   WARNING: The text and links below contain graphic descriptions

If your scribe was the family or carer of an LD adult patient, I would want to know if Rosenthal still resides at Ravenswood but (quite correctly) Southern Health won’t say on confidentiality grounds. Instead, I would certainly want serious reassurances about security (between wards) and expect a site visit.

Rosenthal’s history is detailed here –  in 2008, he had already spent 28 years in Ashworth Special Psychiatric Hospital for murdering his mother and cutting her up with a hacksaw. His Consultant Psychiatrist told Hampshire Police he would be recommending that Rosenthal never be released because he had made absolutely no progress.

Between 2008 and 2013, Rosenthal somehow managed to get transferred to Southern Health’s medium secure unit, Southfields. He hit the news again in August 2013 by absconding. Despite not improving in 28 years in Ashworth,  Southern Health claimed he had made “significant progress and recovery“.

True to form under its old regime, Southern Health misled the press and local residents (of which CRASH is one).

  • They claimed that Rosenthal posed an “extremely low risk” to the public, whilst he was simultaneously described as “potentially dangerous” by police, who issued urgent ‘dangerous, do not approach warnings‘ though the media.
  • They claimed initially that he had ‘gone over the wall‘ on an unsupervised walk in the grounds – only to admit, a few days later, that he had been granted formal leave – from which unsurprisingly he did not return.

Read more here→

Fortunately, the police found him fairly quickly – boozing in Southampton. I suspect this is when he was transferred to Ravenswood. He next made news in 2015 when he was given technical bail, whilst awaiting trial for the murder of his father in France 34 years ago. He had fled from France (before the French police found the body) and returned to Hampshire), where he did the same to his mother. Read more here→

At this point, your scribe reported his concern to the police – Ravenswood had just received a critical CQC report. We pointed out that Winchester Crown Court is as accessible from Broadmoor as from Ravenswood.

Female Detective


The police ‘listened’ and a few weeks later CRASH received a call from a charming female Detective Sergeant thanking him for the ‘intelligence’. Of course, she could not confirm whether he had been moved or not. (Sorry guys, I am sure there are charming male DSs out there too!)



² ‘The proof of the pudding is in the eating‘ is a very old proverb. The Oxford Dictionary of Quotations dates it back to the early 14th century. The phrase is widely attributed to Cervantes in The History of Don Quixote. 

“Our services are now safer”

Nick BDr Nick Broughton: 

Nick joined Southern Health in November 2017 as Chief Executive. He was previously Chief Executive at Somerset Partnership NHS Foundation Trust. Nick is a psychiatrist by background and has worked as a Consultant in Forensic Psychiatry since 2000.

Having commented previously on Mr Justice Stuart-Smith’s sentencing in R v Southern Health NHS Foundation Trust, it is equally important to recognise Nick’s good intentions and the enormity of the task he faces. He started well: in the words of Sara Ryan, Nick:

“Held his hands up to say ‘fair cop’ and accepted systemic failings between 2011-2016…. Broughton’s statement included open acknowledgement of the way in which we’d had to fight for justice and how wrong this was.” 

In Southern Health’s public statement after the Hearing, some of Nick’s words were even stronger: 

“Their [TJ and Connor’s] deaths were avoidable, entirely preventable and should never have occurred.” 

He also had the good grace to credit all those who have contributed to the changes at Southern Health:

“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.”

Also to his great credit a person, who attended Court, alleged that Nick told Trust’s Counsel to shut up when he asked inappropriate questions of Sara Ryan. A welcome change from the lack of ‘guidance’ to Counsel by another Director at a recent Inquest.  

Without apportioning blame, we pose the following questions about the Trust’s statement. They mainly result not from concerns about Nick’s leadership but from doubts about the ability and willingness of some senior and subordinate leaders, still in positions of influence at the Trust, to embrace change fully. For example:

  1. Is it too early to be sure the Trust is a safer place?
  2. Nick recognises the contribution, courage, dignity and insight of campaign activists and others. What steps will the Trust take to ensure all senior and subordinate leaders reciprocate by treating activists and others with respect and dignity?
  3. Many other families lost loved ones as a result of Southern Health’s version of ‘care’: some did not even have the ‘benefit’ of an Inquest. How will the Trust ensure such families do not feel ‘left behind’ by these two high-profile cases?
  4. Does the Trust agree that, although Teresa and Connor’s deaths may have been  catalysts for change, the Trust did not cause the change by self-disclosing incidents to the HSE? For example, a third party reported Teresa’s case to the HSE – almost three years after the event. What steps will the Trust take to remedy this?¹  

Regardless of these ongoing requirements (or perhaps because of them), CRASH is confident that most of those recognised in the Trust’s statement will continue to provide constructive criticism and assist transformation, wherever required. 

Our recent post about the Sentencing Hearing commended Mr Justice Stuart-Smith’s wisdom in setting a well-balanced penalty. Not being present, we were unaware of his ‘bedside manner’ (pun irresistible) but can now quote some of Sara Ryan’s thoughts

“A judgement so drenched in sense and fairness it was extraordinary to listen to. 

“The sensitivity and commitment of the Judge, Bernard, the HSE team and the media who attended (many of whom have followed the campaign over the years) were also extraordinary. Kindnesses that will stay with us. 

“Mr Justice was spot on with his ‘just and proportionate’ outcome.

“[I hope] those more widely implicated [at Southern Health] will absorb some of Mr J’s sense, fairness and integrity and now speak out.”

And that links nicely to Sir Winston Churchill’s description of the Battle of Egypt:

55274608 - statue of winston churchill in parliament square


“Now this is not the end. It is not even the beginning of  the end. But it is, perhaps, the end of the beginning.”

In short, our ‘work’ in respect of Southern Health has not yet ended but we hope that this week’s events mark the end of the beginning of its transformation.




FOOTNOTE 1 – Making life simple in the NHS!

68957027 - which arrow points to my office



Always keen to complicate (whoops) simplify life for NHS employees, from 1 April 2015 our leaders complicated simplified reporting Health & Safety incidents by splitting responsibility between the CQC, HSE and Local Authorities.



Now, rather than just ‘phone HSE (not that Southern Health did so very often), there’s a Memorandum of Understanding to read (and no doubt meetings to be held) just to decide who to contact!

Real Justice at last – £2,000,000


Mr Justice Stuart-Smith



“Exactly right”

© Crown Copyright



The tabloids (aka ‘red tops’) often criticise our Judges for lenient or excessive sentences.

In R v Southern Health NHS Foundation Trust, which relates to the preventable deaths of Connor Sparrowhawk and Teresa Colvin, Mr Justice Stuart-Smith had the difficult task of balancing the gravity of the offences with the effect of a heavy fine on the treatment of future patients.  In your scribe’s opinion, Mr Justice Stuart-Smith’s sentencing was commendable, well-balanced and (in the context of the evidence presented to him¹) exactly right. He concluded:

The end result is reached by reference to my overall conclusion on totality grounds that the aggregate fine to be paid by the Trust is one of £2,000,000. In my judgment a just and proportionate outcome that marks the seriousness of the Trust’s offending, the terrible consequences of that offending, and the other material factors that I have indicated is as follows:

a. On the TJ Charge, the fine will be £950,000.

b. On the Connor Charge, the fine will be £1,050,000.

c. The Trust will pay the Prosecution’s costs in the sum that has been agreed.”

The Judge’ full sentencing remarks are available here→.

Whilst those who inhabit Pollyland and favour Crown Immunity for the NHS will no doubt have a good whinge at the level of the fine, other bereaved families, surviving ‘victims’ of Southern Health and campaigning activists, who have witnessed the dreadful events of the last six years, will realise that £2,000,000 (plus costs) is entirely justifiable.

£2,000,000 pales into insignificance compared with the vast sums of money wasted, for example: on ineffectual leadership training; legal fees in defending the indefensible; and Consultants, whose recommendations the Board generally ignored anyway.

In the context of the Trust’s expenditure during the same four years, the £2,000,000 fine is peanuts. Yes, it could have been spent on patient care but so could the £5,000,000+ Percy spent with an acquaintance on clearly ineffectual leadership training for current and future bureaucrats. Read ‘The Value of Life’ here→ and ‘The talented Mr Martin and viral impact’ here→

Percy Cleaning Loos


It’s a shame that the culpable CEO (Katrina Percy) did not have to stand in Court during sentencing; could not have spent a few weeks as a guest of Her Majesty; could not have been set to work for a year in a ‘Hi Viz’ jacket  cleaning Southern Health’s loos; or perhaps all three!

However, even if this could have been done legally, it would be very difficult with this printed in the Trust’s 2016/17 Annual Report (page 57):   


“Payments for loss of office – Information Subject to Audit”JD re KP credit 002 [Information about other officials redacted)JD re KP signature

Quite why Julie Dawes was minded to put her signature to nonsense such as, “Katrina was fit to lead” (I know!) is a complete mystery: she knew exactly how Percy had failed. HM Treasury must have misplaced their collective brain in considering it an appropriate use of public funds. ‘The Daily Telegraph’ described it as, “Scandalous Largesse.”   

¹  We have some reservations about statements made to the Judge by Counsel and about the Trust’s press statement but these are for another day. We do not wish to detract from the wisdom of Mr Justice Stuart-Smith. 

Right to Freedom & Safety

An opportunity to contribute to a change in the law!68525046 - silhouette bird go out of cage in freedom concept in sunset

The Joint Committee [of the House Lords and the House of Commons] on Human Rights  (“JCHR”) yesterday issued a Call for Evidence for its inquiry, ‘Right to Freedom and Safety: Reform of the Deprivation of Liberty Safeguards‘.

This is a rare opportunity for patients, carers and families affected  by The Mental Capacity Act 2005 and associated Deprivation of Liberty Safeguards (“DoLS”) to make their views known to a highly influential Parliamentary Committee. This probably includes many readers of and contributors to this blog and that of Dr Sara Ryan.

These are extracts from the Committee’s announcement:

“The right to personal liberty is one of the most fundamental human rights, and can be traced back to Magna Carta. Article 5 ECHR provides that everyone has the right to be free to come and go. No one may be deprived of liberty without a legitimate reason. If a person is deprived of liberty, certain safeguards must be provided; these include entitlement to take proceedings by which the lawfulness of the detention is decided speedily by a court, and the person’s release if the detention is not lawful.

“The Deprivation of Liberty Safeguards (DoLS) scheme, set out in the Mental Capacity Act 2005 (MCA), safeguards against arbitrary detention for people who are deemed to lack capacity to consent to their care or treatment. The DoLS aim to ensure that people are only deprived of their liberty when it is in their best interests and there is no other less restrictive way to provide necessary care and treatment.

“In 2014 the Supreme Court decision in the case of Cheshire West significantly widened the definition of a deprivation of liberty. The judgment has resulted in a tenfold increase in the number of DoLS applications being made in recent years. Local Authorities have struggled to cope with the resource implications of the judgment and a very large backlog of cases has built up.

“Immediately prior to the Cheshire West judgment, the House of Lords Select Committee on the Mental Capacity Act had concluded ‘[…] far from [DoLS] being used to protect individuals and their rights, they are sometimes used to oppress individuals, and to force upon them decisions made by others without reference to the wishes and feelings of the person concerned.’ They have also been widely criticised for being overly complex and bureaucratic.”

“In response to this situation the Government asked the Law Commission to look at ways to reform the legislation in this area. In March 2017, the Commission published its final report Mental Capacity and Deprivation of Liberty which called for DoLS to be replaced ‘as a matter of pressing urgency’ with a new scheme called the Liberty Protection Safeguards (LPS). On 30th October 2017 in a Written Ministerial Statement, the Health Minister issued an interim response to the Law Commission’s report, undertaking to engage in a further period of consultation and promising a final response in spring 2018. [Read the interim response here→]

“The Committee is issuing an open call for evidence from interested parties and would welcome written submissions by 2nd March on:

  • Whether the Law Commission’s proposals for Liberty Protection Safeguards strike the correct balance between adequate protection for human rights with the need for a scheme which is less bureaucratic and onerous than the Deprivation of Liberty Safeguards;
  • Whether the Government should proceed to implement the proposals for Liberty Protection Safeguards as a matter of urgency; and
  • Whether a definition of deprivation of liberty for care and treatment should be debated by Parliament and set out in statute.

Submissions should be no more than 1,500 words.”

Read more on submitting evidence to Select Committees here→. The JCHR’s prefers evidence submitted via its web portal here→.

If you do not have time to prepare a written submission, you can email any observations to CRASH via the ‘Contact‘ page. If appropriate, we will consider using it in our evidence.

CRASH has submitted evidence to the JCHR previously – on a different subject. The Committee published it and used sections verbatim in it’s Final Report. It was  a productive exercise.

CRASH’s tips on submitting evidence to Committee Inquiries

  1. The JHCR is not able to investigate individual cases but such cases can be used to illustrate specific points.
  2. Do not comment on matters currently before a court of law, if Court proceedings are imminent or if a police investigation is in progress without first seeking advice from the Clerks to the Committee: the JCHR may publish evidence anonymously in these circumstances – although you still have to disclose your name to the JCHR. 
  3. Do not publish your evidence elsewhere before the Committee publishes it. Committees tend not to consider pre-published reports.
  4. Evidence published elsewhere under the authority of the Committee only attracts Parliamentary Privilege if published after Parliament publishes it.
  5. If you publicise or publish your evidence yourself must indicate that it was prepared for the Committee.
  6. BE BRIEF (very difficult for CRASH!): include a bullet point Executive Summary on page 1 of your submission.
  7. Read carefully Parliament’s Guidelines for submitting written evidence to Committees here→ and cross-check them with instructions for the individual Inquiry – for example, the number of words allowed often varies.
  8. CRASH has always found Clerks to Committees very helpful, especially to ‘newbies’: contact them by email or telephone.

CRASH’s recommendations on attending Committee Hearings

  1. Committee Hearings are held on the Parliamentary Estate and mostly in public.
  2. Although it is rare for members of the public to be asked to give verbal evidence, it can be fruitful to attend at least one Hearing.
  3. Witnesses are named and Hearing dates announced in advance – pick a day when a person of interest to you is giving evidence. There can be opportunities to talk to  witnesses and Committee Members in the corridor before and after Hearings or during a break in proceedings: CRASH found this productive. 
  4. It is helpful if you can recognise Committee Members: information here→. Knowing names is invaluable. If your MP sits on the Committee, so much the better.
  5. Whether or not your MP is a Committee Member, inform them you are submitting evidence and, if you attend a Hearing, send advanced notice¹. They may agree to meet you.
  6. If visiting Parliament arrive at least 60 minutes early to allow time to pass through airport-type security and find the Committee Room. Queues can be especially long on Wednesdays when Prime Minister’s Questions are held.

Further Information:

Website: http://www.parliament.uk/jchr     Email: jchr@parliament.uk

Watch committees and parliamentary debates online: http://www.parliamentlive.tv

¹ To obtain MPs’ contact details in Westminster, put their given name, surname and “office” into the search engine on Parliament’s web site

‘Third World’ NHS Care

Anyone reading this blog might be interested in the following recent reports and blogs, which are highly recommended. 


84008918 - trapped rubber stamp

Hundreds of thousands of disabled and ill people in the UK are being detained unlawfully in care homes and hospitals, according to a new report by the Law Commission.

The Commission claims that proper processes and checks are not being carried out in many cases. Read more here→

[Original source: Sandi Beers]




Documents the lack of specific understanding that exists in Government on mental health issues. “The question and the Government response is incoherent→” 



Anorexic student, 19, starved to death after she was failed by ‘Third World’ NHS care:” 



The deeply moving, sad story of Avril Hart and her family’s five-year fight for justice told by her father.

© Nick Hart


Another story of multi-agency failure in NHS, including references to: 

  • Delays.
  • Refusal to answer questions.
  • A convoluted system preventing the full facts from emerging.
  • Additional notes made on medical records two weeks after death. 

[Original source: ‘The Daily Mail’ 8 December 2017 (Warning: contains graphic image) and Fully story here→


89144385 - woman prisoner isolated on whiteCriminal Convictions

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

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


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

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

Should Crown Immunity Apply to the NHS?

49651000 - royal gold crown


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


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

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

Doctor in ChainsCrown Immunity and the NHS 

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


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

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

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

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

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

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

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

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

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

44734657 - sas word representing special air service and special forces

Crown Immunity in the Military

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


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

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

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

So should Crown Immunity be reintroduced for the NHS?

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

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

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

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

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


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

²  Polly Toynbee –

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

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

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

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


Small steps…

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

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

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

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

Card - Liz - Copy (3)


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

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

The Law of Marginal Gains¹:

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

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

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


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

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

Cost and Care:

Baby Birds

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

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

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

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

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

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

Small steps big changes 2


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

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




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

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

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

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

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

¹ Sir Dave Brailsford – [Harvard Business Review]          

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

The Value of Life

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


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



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






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

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

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


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

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

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

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



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

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

Stevens - money 2£987,000?¹

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



Sandra with cash & gold 2


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



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

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




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

£170,000 – £180,000?¹

33596896 - girl at atm

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

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


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

“Fair payment in all the circumstances”¹

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


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

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

District Judge Loraine Morgan said:

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

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

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

Read more here→.

Money not available your Honour?

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


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

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

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