Taking stock and fisking Southern Health’s CEO #justiceforLB

Much to the delight of Where’s Wally enthusiasts, Southern Health’s Chief Executive finally turned up this morning, on BBC Radio Oxford. The main interview with her begins at around 2’08” here.

The CEO and Trust is clearly receiving public relations and crisis communications input at the moment. The quality of interviews with the CEO and other Southern Health Executives so far would suggest they should be asking for a refund, so transparently have they stuck to the pre-agreed lines and so poorly have they responded to actual questions put to them.

Before I go through in some detail the ‘contents’ of the CEO’s interview this morning, let’s just take stock of where things are:

• The damning independent inquiry into Connor’s death was published last week
• We know CQC has previous on this – most specifically in the case of Hannah Groves and at least one other publically known incident
• CQC has since published two further reports highlighting the need for enforcement and improvement actions, quite aside from actions already required at Slade House
• Monitor is currently investigating Southern Health’s licence because of concerns raised by CQC
• BBC Oxford, other local press and specialist press – such as Community Care and the Health Services Journal – have picked up the story so far
• FOI and DPA requests to Southern Health are being submitted soon, along with a list of the remaining key questions (it’s a long list).

Progress, but we’re yet to hear from:

• Southern Health’s Board – their Chair or any other Non-Executive Director (if this happens then I predict trouble for the CEO and her Executive Team)
• Southern Health’s Communications team (who have mostly been blocking people on Twitter and, erm, not tweeting for 5 days and counting…)
• Local commissioners – CCG or Local Authority (Members or Officers)
• Department of Health, especially the Care Services Minister or SoS for Health
• NHS England (though at a personal level key people within NHSE are very much engaging)
• National press.

If a ragbag of (angry) people/bloggers/social media folk have rightly helped keep this going so far, quite aside from the incredible @sarasiobhan, then what makes Southern Health think this is going away? My blogging efforts (just as one example of very many) will be nothing compared to the scrutiny Southern Health would be under if any of those we’ve yet to hear from start properly picking this up.

Anyway, below is a fisking of the CEO’s interview this morning. (By the way, Phil Gayle of BBC Oxford should be congratulated on not just a brilliant job putting key questions to the CEO, but also continuing to focus on this story long before most other media outlets have considered it.)

Before you read the full thing, there is one major point to note: having listened to this very carefully and transcribed it, I cannot find one occasion on which Southern Health’s CEO says “sorry” or apologises in any way at all. I’ve said before that Southern Health can sink to depths to which even we thought they could never sink, and they’ve only gone and done it again.

Phil Gayle, BBC Oxford (PG): What action has being taken since Connor died?

Katrina Percey, Southern Health CEO (KP): There are a lot of changes that I am aware of…

Note the passive tense here, not “responsible for”, not “leading”, not “requiring”, but “aware of” changes: KP’s first response is one that immediately attempts to distance herself from the situation.

(KP) … it was one of the key things handed over to me on my return from maternity leave at the end of the year…

“I wasn’t here when it happened, gov – nothing to do with me.” A further attempt at distancing.

(KP) … One of the very immediate things that happened, within hours, of his death was to review our epilepsy risk management and risk assessment processes, and to look across the org at those processes.

If epilepsy was known to be a contributory factor to Connor’s preventable death, to the point where risk management and assessment were reviewed “within hours”, then why did an internal report conclude he died of “natural causes”? Notwithstanding this, reviewing processes is very different to changing them or actually using them (which KP later highlights didn’t happen anyway).

(PG): There were months between Connor’s death and the CQC inspection.

(KP): It is a very difficult situation and it was absolutely awful situation to find that there were still things being found in that unit around some elements that you’re able to correlate across to Connor’s death.

The “awful situation” here seems to be that things were still being found in the unit, rather than the fact Connor died a preventable death.

That “some elements” rather undersells things, doesn’t it? CQC failed Slade House on all 10 standards they inspected. Of these, six had enforcement action taken, including on (a) Care and welfare of people; (b) Assessing and monitoring the quality of service provision; and (c) Records. That isn’t some elements; that’s all of them.

And “correlates across” to Connor’s death? Correlation and causation are, as anyone will tell you, two very different things. Fortunately, Verita’s independent inquiry, by robustly and unambiguously concluding Connor’s death was preventable, means there’s less “correlation” and more “cause” here.

(PG): Please put it in simple terms. An 18yo boy dies in your care. His death could’ve been prevented. After his death you say you made changes. Months after his death the CQC inspects the changes that you say you’ve made and still finds them inadequate. Now either they aren’t doing their job correctly or you’re not.

(KP): All I can say is that there were changes made immediately after Connor’s death.

The Care Quality Commission visited the service in question on 16, 17 and 23 September 2013, two months after Connor died. It is simply not true that changes were made immediately. Either that, or the changes made were completely ineffective. That’s not great, whichever way you look at it.

What’s more, we know from the (preventable) death of Hannah Groves that Southern Health made a series of public and internal commitments about what they would do to (a) improve the relevant service; and (b) ensure it wouldn’t happen again. CQC inspections have shown that the relevant service got worse. And not only did it happen again, but each of the elements of learning and action arising from Hannah Groves’s case were contributing factors to Connor’s death.

(PG): Do you accept that the changes that were made after Connor’s death were inadequate as the CQC found. Who isn’t doing their job?

(KP): Yes. I mean clearly we didn’t do enough because if we’d done enough then the CQC when they came in several months later they wouldn’t have still been able to find things they weren’t happy with.

It’s not a case of having not done enough; it’s a case of having done absolutely nothing that was effective.

Note also here that it’s things CQC weren’t “happy with”. Sometimes I’m not happy with how my hair looks in the morning or how much milk is in my coffee. The things CQC weren’t “happy with” included the care and welfare of people, and the assessing and monitoring of the quality of service provision – pretty fundamental things for, I dunno, an NHS organisation.

(PG): So, who did a bad job?

(KP): So, similar to Piggy Lane, what we found is that some of our own processes have failed us because people were telling us that they had inspected equipment and things like that and when they were checked by the CQC they actually hadn’t

There’s something of a mix-up here. In the first place it’s the processes that failed, and then it becomes people saying things had happened when they hadn’t. What Verita found in their independent investigation is that Southern Health has a range of policies and guidelines that provide the framework within which their ‘care’ is provided, but that this paperwork was only that, paperwork. Verita also found a unit which  “lacked effective clinical leadership and operated a team-based approach in which no individual/s held the responsibility for ensuring that the care and management of [Connor] was appropriate and coordinated effectively.”

Thus, I suppose KP is right in the fact fact that both things she mentions – effective people and effective processes – were missing.

The other point here is the issue KP chooses to highlight: equipment and “things like that”. The “things like that” which CQC found included: “People did not always experience assessment, care, treatment and support”; “There appeared to be an impoverished environment with little therapeutic intervention of meaningful activities to do”; “Whilst much audit work was undertaken, there was little that impacted positively and directly on the care of the people that were being looked after on the STATT unit”; “The provider did not have an effective system in place to identify, assess and manage risks to the health, safety and welfare of people using the service”.

Y’know, just small “things like that”.

(PG): So, once again we’re in both situations at Piggy Lane and at Slade House where, as you tell it, staff are giving you false reports about what is going on on the ground.

(KP): I would agree that we have received false positive assurance. What we try to balance that with is trying to help develop our staff and help them understand the tools they have at their disposal to improve the services.

“Yes, I’d agree that staff lied and felt no responsibility and accountability, but what we do is try and help them to get better.” Might I suggest that some such tools they have at their disposal include: listening to the families of people in their ‘care’; not shutting themselves in offices to do administrative tasks; and not, erm, lying.

(PG): These false positives that you say are in both instances. Has anyone been disciplined for that action?

(KP): There’s been a number of management changes already, and there are 7 people undergoing HR investigations currently.

The only genuinely useful piece of information in this whole interview.

(PG): Are these at Slade House or at Piggy Lane?

(KP): They work in our services.

Blow me down. Where else were they likely to be working?! That’s at least 25% of the PR fees Southern Health have spent that should be returned immediately.

(PG): Which?

(KP): I think one of the things that you want to do is while we run through a process we want to protect the people because we don’t want to say people are effectively guilty until its been proven.

Hang on a sec! At at least two other points in this interview you were blaming your staff and distancing yourself from the whole situation. Which one is it? Supporting the staff or blaming them?!

(PG): Ok, fine. But you can tell us whether staff at Slade House or Piggy Lane are being disciplined – you don’t have to name them – what people listening want to know is which staff in which of these units are being disciplined?

(KP): There are staff under investigation across those units.

(PG): Across both units?

(KP): Yes.

I wonder when these investigations started, by the way: immediately after Connor’s preventable death? after the CQC’s inspection of Slade House? when Verita produced their damning independent inquiry? when anyone actually started asking questions about all of this?

And no mention here of at least one other service that has recently been failed by the CQC (Antelope House in Hampshire). I wonder if staff are under investigation there, too?

(PG): You are at great pains to protect the staff there.

(KP): Yes.

Apart from when you were blaming them earlier.

(PG): Do you believe the staff were at the same level of pains to protect the patients… and what we have again here is staff telling you they’ve fixed this, they’ve fixed this, they’ve fixed this, when they haven’t. Shouldn’t your concern be more for your patients than for your staff?

(KP): Absolutely, our concern is always for our patients…

I’ve got 3 CQC inspections published in the last 6 months for services in one area that shows that isn’t correct.

(KP) …When I heard about the death of Connor, it felt absolutely devastating. As a mother myself, I cannot imagine how absolutely unbearable it must be when your child dies. And that constantly, many of us are parents, that constantly sits with us….

There are so many things wrong with this, most of which it isn’t my place to highlight. The one I will mention is the unbelievable chasm between KP’s words and the actions of her organisation in the days, weeks and months since Connor’s preventable death, including how her supposed “empathy” never, at any point, translated to treating Connor’s family with any sort of respect or dignity.

(KP)… I think the challenge is that our staff come into work to do the best they can…

Yes, I thought those four staff noted by CQC doing administrative tasks in an office that had absolutely no impact on the quality of care received by people at Slade House was a clear demonstration of this. Another particularly poignant example of your staff’s best was when one of them described Hannah Groves as a “fucking waste of time” and “an attention seeker”, leading to Hannah’s suicide.

(KP)… and talking with staff they are absolutely desperate and they are also absolutely devastated that Connor died in our unit.

I’m sure that’s right. It clearly comes through in S1’s reflections during their interviews with Verita, saying, for example: “I don’t do that. I don’t sit down and write an entire document about what every other professional is doing because that wouldn’t be appropriate for me to do.” But, bless them, they were thrown out of their stride and needed time to recover because a, erm, CPA meeting didn’t follow the “set format”.

And who can forget S3’s contribution to Connor’s preventable death? How they talked to the family about whether they could visit or not; what they had to say when Connor’s younger brother wanted to visit the person he’d shared a room with for his whole life; how they thought (a) it was reasonable to put an 18-year-old to bed at 7pm and (b) contradict their own unit’s visiting hours in order to deliberately prevent Connor’s parents from seeing their son.

Perhaps staff are “absolutely desperate” because, according to their own staff (in CQC’s inspection of Piggy Lane) they felt they are “badly managed” and “’let down’ by their employing authority, Southern Health”?

(PG): Can we go back to the way that Southern Health is run? The business you run could have prevented the death of an 18yo boy. The business that you run has been found to be inadequate. Two separate units of the business that you run. How much personal responsibility do you accept for this? Are you thinking about resigning?

(KP): It’s absolutely devastating to hear that somebody has had a preventable death in our care and that our services don’t provide the quality in these two units…

This is just supposition, but I don’t think KP even heard the word “resignation”, quite aside from not answering the question. (Compare and contrast David Nicholson’s direct engagement with a similar question.) In all of KP’s responses, there is a very distinct lack of culpability, responsibility, accountability etc. Sometimes it’s explicit (“I was on maternity leave”) and sometimes it’s implicit (“I would agree that we have received false positive assurance”), but it’s definitely there.

(KP)… We run a very very wide range of services and some of them also have quality improvement plans in place…

This is the PR attempt to try and isolate the issues that have been identified within Southern Health, by implying that the vast majority of services they deliver are ok. The difficulty with this is the fact they have a lot of prior. As has previously been demonstrated, the way they dealt with Hannah Groves’s (preventable) suicide led to the service in question getting worse, and is also exactly the same set of actions they’re undertaking at Slade House, which had had no impact between Connor’s preventable death and the CQC inspection. What’s more, two further services have been publicly failed by the CQC, quite aside from any other services for which inspections or investigations are outstanding.

Even if it isn’t easy to identify at what point an isolated service failure becomes wider, institutional failure, it’s safe to say Southern Health passed that point some time ago.

(KP)… What I’m trying to do is lead an organisation to make the changes, to develop the staff, to empower the staff, to really deliver the quality of care that’s needed for our services.

Well, she is an award-winning leader, after all.

By the way, I checked the NHS’s Healthcare Leadership Model. It includes Connecting Our Service (“Understanding how health and social care services fit together and how different people, teams or organisations interconnect and interact”) and Holding to Account (which doesn’t include “Setting unclear targets; Tolerating mediocrity; Making erratic and changeable demands; Giving unbalanced feedback (too much praise or too little); Making excuses for poor or variable performance; Reluctance to change”).

(PG): So that sounds like a really long way of saying you won’t resign.

(KP): I think there’s a lot of evidence from the services that we provide across a very large organisation about the work that we’ve been leading really does improve the services to patients…

There’s that word “lead” again. She’s a leader, doncha know?

And I’d love to see the evidence KP has, partly because if they take the time to publish the good stuff then that shows even more starkly how little they’re doing in publishing and engaging with the bad stuff.

(KP)… And what I want to do is make sure we do that to all of the units in former Ridgeway area.

This is another PR line: make it seem as if all the problems relate to the previous provider. The difficulty here is that Southern Health explicitly committed, on their website, no less (way to go, comms team!), to delivering “[t]he same services and the same staff will still be working in the same locations.” So, quite aside from the time elapsed between Southern Health’s takeover and the timing of the current issues, it’s either the case that Southern Health felt comfortable with the services and their quality that they inherited, or they did nothing to improve those services.

(PG): Given these reports from the CQC into these two units, do you believe that you are doing your job well enough as CEO

(KP): There’s always, for all of us, things that we could do better, and I spend a lot of time reflecting and getting feedback about how I could do my job better, as do all of the leaders in our organisation.

To be fair to KP, there’s really only one way for Southern Health to go, isn’t there? Though they do keep doing their best to find new depths they haven’t yet plumbed.

(PG): So, an 18yo boy died in your care that was preventable. One person was allowed to leave the buildings unseen and unsupervised. One resident was physically assaulted by someone in town and on a third occasion a car reversed into a person in a wheelchair. You have told us that you keep getting false positives from the staff you employ, they tell you one thing when the other is actually the case. For those parents and guardians of people in your care, this looks like Southern Care is in chaos. Is it?

(KP): I don’t, I mean, this is devastating…

For your award-winning leadership? Yes, it is.

(KP) … and I can’t express enough how devastated enough this is for the family of the person who died and some of the people who have not been getting the quality of care that they should expect from our services…

The person? Fuck me.

And what she’s actually saying here is she can’t describe how devastating this is for the people who actually experienced Southern Health’s multiple fuck-ups.

(KP) … My assurance would be that all of our energy and our drive and our passion is going to improving the quality of services that we offer.

This “energy, drive and passion” has so far led to:

• Two preventable deaths
• Four services in two different areas so far independently reviewed by the CQC as being significantly failing
• A complete lack of engagement with Connor’s family to the extent that Southern Health’s behavior has been bullying and aggressive
• Questionable co-operation with the independent investigators exploring Connor’s preventable death
• KP not appearing personally until 9 days after the independent inquiry into Connor’s preventable death was published.

May I modestly suggest that any “assurances” provided by Southern Health are meaningless. I wonder when the Board and all those others who are yet to engage will notice, pick this up and ensure accountability and #justiceforLB?

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