“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 

Basil Fawlty?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Stage 2 – Fact Check  

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

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

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

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

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

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

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

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

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

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


Who should be more concerned?

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

More on Mr Basil Aidan Fowler to come.



Red words Warning Gaslighting detected

On 9 February 2020 we reported the result of an ‘independent’ report on Southern Health NHS Foundation Trust under the headline:

Truly deplorable and unacceptable saga

In his report (here) Mr Nigel Pascoe QC recommended a two-part Public Investigation –firstly into the death of one patient and secondly into the Trust’s current performance in limited respects.

It pains us to report that, despite the families struggling for almost 12 months to negotiate Terms of Reference (“TORs”) and Procedures with Ruth May, Chief Nursing Officer for England (“CNO”, also a director of NHSE/I) and Mr Pascoe, they refused to listen.

Describing the investigation as a charade, the families allege that they had been misled, misrepresented, gaslighted and bullied. The full, unabridged Family Statement is here→.

Read and weep – CRASH has known these families since 2016. They have been struggling for justice for up to 10 years and have been brutally shut down at every stage.

blue blowtorch

We have known of this for over a week but, from experience, it is more effective to give national media ‘first dibs’, not scoop them!

It also make life easier for us. Readers can just follow these useful links:


BBC NATIONAL – ‘Southern Health: Bereaved families ‘gaslighted and bullied‘ by NHS by Michael Buchanan, who has doggedly followed the story since 2016. In addition, BBC South Today has covered the “Charade” already on two separate occasions, fronted by the excellent James Ingham, who reported on the Inquest into the death of Ellie Brabant. It’s was also on BBC radio and even CEEFAX.    

‘NURSING TIMES’ – ‘Families ‘lost all trust’ in inquiry commissioned by CNO‘: a fearless article considering it relates to the Chief Nursing Officer for England, Ruth May. 

FREE ACCESS: you can register for a week’s free access to ‘Nursing Times‘: that way you can see the hurtful comments made about the families too, especially by NHSE/I (family blame) and (to a lesser extent), Southern Health’s Medical Director, Dr Karl Marlowe

TWITTER©: there is considerable activity in the Twittersphere too: follow the links on the names, (You can access these threads without registering with Twitter©).     

  • Rebecca Thomas – senior reporter, Health Service Journal (“HSJ”). 
  • George Juliantireless supporter of improvements for those with learning difficulties, who we first met in 2016 as supporter of Dr Sara Ryan.a mother of ‘Laughing Boy’. Starting with a recap of the Connor Sparrowhawk case, this is a long thread but well worth a read. WELL DONE George!
  • Alison Moore – another HSJ reporter scroll down the page to 3 February 2021.
  • Dr Sara Ryan – mother of ‘Laughing Boy‘ – Sara has been twittering for a long time (111.9K Tweets + so, as they are in reverse date order, here’s her first reaction:  

    Sara's Tweet (reduced)

    Well done Ruth May and Southern Health – you’ve even succeeded upsetting a bereaved family, who’s not even involved in this investigation. 

The TORs and Procedures for the Public Investigation are available here if service users, carers and families wish to participate. Beware of the tight deadlines; restrictions on what you can say; and practical and technical requirements. We do not wish to see families and service users drawn into what appears to be a virtue signalling exercise.

If having read this post, the TORs and the procedures, you wish to express your views on the process. You can email Ruth May here and Mr Pascoe QC here, as well as leaving comments below.

In memoriam:

Edward Hartley and Connor Sparrowhawk, two much-loved young men lost far too early:

Edward 2


Edward      © Ian Hartley



Connor © Dr Sara Ryan

Substantial Meal?



Three month’s since our last post – so much has been happening at Southern Health NHS Foundation Trust that the moment we were ready to write a new one, something else cropped up. So, for a change, we’re going to poke some fun at the government.

This week alone, we’ve heard lots of stories about, “Substantial meals.”

Environment Secretary George Eustice said a Scotch egg, “Would probably count.”

Yesterday, Minister for the Cabinet Office, Michael Gove said:

“As far as I am concerned it’s probably a starter, but the broader, more serious point we need to establish is there are reasonable rules which are there to keep us all safe.

“It’s a definition in law that has existed for years now, if I wanted to take my 16-year-old son or 17-year-old daughter out to the pub, I can buy them an alcoholic drink provided it’s with a substantial meal. “Well it’s [a substantial meal] been defined in law for years now. The law was passed long before I became an MP.”

“My own preference when it comes to a substantial meal might be more than a scotch egg, but that’s because I am a hearty trencherman, “The serious point is the pubs have known for years now what a substantial meal is… I think you are being unfair on the hospitality sector.”

Mr Gove was right to say that a substantial meal had been defined in law before he became an MP in 2005. I wonder why the government’s legal army didn’t brief Ministers properly. Perhaps Sir Humphrey Appleton QC thinks he’s too important to read the Law Society Gazette, which ran an article on the subject as recently as 13 October 2020! 

The definition is to be found, not in formal legislation, but in common law.

The story behind Timmis v Millman (1965) 109 SJ 31 goes that two men were in a hotel bar at 11.30pm consuming alcohol outside permitted hours (but within the supper hour extension of the time). Lord Chief Justice, Lord Parker found that the sandwiches the pair were eating:

“Were so substantial, and assisted by the pickles and beetroot so as to justify that it was a table meal and not a mere snack from the bar”.

This followed the case of Soloman v Green (1955) 119 JP 289, where sandwiches and sausages on sticks were found to amount to a meal.

Read more on the website of Trinity Chambers, where specialist barrister Charles Holland, who first tweeted about on the subject, is a tenant:

So it seems that a Scotch egg alone is NOT a substantive meal but it might be if accompanied by a decent sandwich and a few extras.

ploughman's lunch on a white plate, top view


This is what we call a substantial meal!

Toast, cheddar cheese, apple, scotch eggs, sliced head cheese, tomatoes, spinach, hot mustard, pickled onion – a traditional ploughman’s lunch.


I’m not sure if this is any clearer but this is the law unless/until another case comes to Court – if anyone is foolish enough to incur substantial legal expenses! Of course, there could be many fools in Government – and they’d be using our money not their own!

Girl with bunny ears with ostrich egg on a colored background.


And finally, although we don’t want to make a meal of it (sorry), is a Scotch egg made from an Ostrich egg¹ a substantial meal?




Dido1 001


Or the egg of the Dodo bird?²


Private Eye



¹ Ostrich eggs are the largest of all eggs – on average they are 15.9 in. long, 5.1 in. wide, and weigh 3.1 lb, over 20 times the weight of a chicken’s egg

² The size and shape of Dodo eggs are unknown.

Electroconvulsive Trauma?

EEG Electroencephalogram, brain wave in awake state with mental activityIs 80 Years of Electrocuting the Brain Enough?¹

Southern Health NHS Foundation Trust clearly doesn’t think so! In a training video on depression, the tutor (a Registered Mental Health Nurse) can be heard saying of Electroconvulsive Therapy (“ECT”) to three other mental health nurses [paraphrased]:

“[Is] very old… seems a bit strange…. seems to improve mood when really  depressed – it’s really effective, we don’t know why or how [but] it works for a lot of people.”

We invited Dr John Read, lead author of recent academic research detailed below, to view this training video. He responded:

“Had a quick look. Irresponsible not to mention brain damage/memory loss.”

The wife of a Southern Health patient, known to us, agrees with Dr Read. She describes the effect of ECT on her husband:

“Memory fried, executive dysfunction. Can’t work or live independently”²

I wonder why Southern Health doesn’t use this example in its training video?

Electroconvulsive therapy. Vector icon.

So what is Electroconvulsive Therapy, as it is deceptively known?

It is the application of electrodes to the head to pass electricity through the brain with the deliberate goal of causing an intense seizure or convulsion.  


Electroconvulsive “therapy” is a misleading term. It’s detractors say ECT is not a therapy: it damages the brain. Called, “A Crime Against Humanity” by Wayne Ramsay JD, Electroconvulsive Trauma might be a more accurate term.  

Harvard-trained psychiatrist, Peter R. Breggin MD, called “The Conscience of Psychiatry” for decades of successful efforts to reform the mental health field, writes of ECT:

“Abundant evidence indicates ECT should be banned. Because ECT destroys the ability to protest, all ECT quickly becomes involuntary and thus inherently abusive and a human rights violation. Therefore, when ECT has already been started, concerned relatives or others should immediately intervene to stop it, if necessary with an attorney.” Read more here→

In November 2019, Ethical Human Psychology and Psychiatry³ published peer-reviewed research by John Read PhD, University of East London, Irving Kirsch PhD, Harvard Medical School, and Laura McGrath PhD, University of East London. They concluded:

“The scarcity and poor quality of most of the findings suggesting that ECT has short-term benefits for some depressed people, the complete lack of evidence of long-term benefits, and the absence of evidence that it prevents suicide, together with the high risk of permanent memory loss and small increased risk of death, broadly confirms the conclusions of previous reviews…. For example (Read & Bentall, 2010):

“‘Given the strong evidence of persistent and, for some, permanent brain dysfunction, primarily evidenced in the form of retrograde and anterograde amnesia, and the evidence of a slight but significant increased risk of death, the cost-benefit analysis for ECT is so poor that its use cannot be scientifically justified (p. 333). . . . The very short-term benefit gained by a small minority cannot justify the significant risks to which all ECT recipients are exposed.'” 

The BBC also wrote about the research on 3 June 2020, ‘ECT depression therapy should be suspended‘ quoting the conclusion of the research:

“The high risk of permanent memory loss and the small mortality risk means that its use should be immediately suspended”.

The lead author, Dr Read’s opinion of previous research justifying use of ECT is:

“The lowest quality [research] of any I have seen in my 40-year career.”

The US Citizens Commission on Human Rights claims that the ECT death rate is 50 times higher than the US murder rate. The Commission provides ‘Quick Facts’ about ECT here.

Leading neurosurgeon Dr. Norman Shealy says:   

“One fact about ECT: It damages the brain. Period…. ECT should have been banned 50 years ago.”

What ECT Survivors Say  (Warning: the four videos here are distressing).

After 2009, UK law was altered so that ECT cannot be given to any patient who is able to refuse consent. However, emergency administration is still allowed regardless of capacity to consent and, in the case of a patient who lacks capacity, regardless of the wishes of the patient’s nearest relative. I know two nearest relatives of Southern Health patients, who say their loved one’s lives have been wrecked by ECT given against the relatives wishes. 

ECT has been banned in some countries, including Italy, Slovenia, and some cantons of Switzer­land (according to Larry Tye in his ironically titled book Shock: The Healing Power of Electro­convulsive Therapy,’ [Penguin 2006, p. 22]).

On 2 July 2020, 40 mental health professionals and researchers, and ECT recipients
and their family members, wrote an open letter to Peter Wyman, Chair of the CQC to request that ECT be immediately suspended throughout the NHS, pending further 
research to determine its efficacy and safety. Read the media release here→

The letter itself (available here) was copied to Ministers and the CEOs and Medical Directors of all NHS mental health trusts.  

Let’s not wait another 50 years!
Italiy Flag                              Slovenia_Flag5                              swiss flag

HASC Chickens

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

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

family portrait poultry chicken, red rooster bright yellow littl

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

Young woman talking with psychologist

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


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

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

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

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

Truly deplorable and unacceptable saga

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

Legs of a snowboarder stuck in snow

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

Duck looking for food in a lake

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


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

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

Surely not.


Care[less] Quality Commission

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

“Very little improvement in peoples’ recorded feedback”.

Sick Bag 2

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

Pass the sick bag!


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

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

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

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

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

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

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

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

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

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

Broken Trust

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

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


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

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

A reviewer on Amazon comments:

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

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

Planning to Fail

dav© James Whitworth¹

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

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

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

OAP Graph - Copy

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

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

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

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

BUT BEWARE is skulduggery afoot? 

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

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

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



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


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

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

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

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

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


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

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

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

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

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

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

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




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




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

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

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

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

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

³ PICU – Psychiatric Intensive Care Unit