Questioning Southern Health’s future fitness for purpose

In any complex system it’s inevitable that mistakes will be made that have tragic consequences. Supporting, caring for and enabling people with learning disabilities or mental health problems is precisely a complex system; the goal of such a system has to be to maximise good quality care and support for as many people as possible, so that they can lead equal lives, and minimise tragic and very poor quality situations as much as possible.

The reasons why I am so angry with Southern Health are multiple, but especially include the way in which they have abrogated their responsibilities at every single juncture, before and after, when it comes to Connor Sparrowhawk –a brilliant 18-year-old, son, brother, friend who died a preventable death in the “care” of an institution run by Southern Health. The latest in a very, very long line of examples is them protecting their account on Twitter, following a distinct lack of any leadership from their, erm, leadership award-winning Chief Executive.

What I was personally aiming/hoping for through #justiceforLB was 3 things:

  1. Justice for Connor (or “Laughing Boy” (LB), as his mum called him)
  2. A line of influence that directly connects what happened to Connor with work being done with the approximately 3,500 people with learning disabilities who still “live” in and are “cared for” in (post-)Winterbourne View-type institutions
  3. A wider call to action about how to achieve equality of opportunity for people with learning disabilities, mental health conditions and, indeed, all disabled people.

If Southern Health had simply done what Connor’s mum outlined in her post “Imagine” after his preventable death, then #justiceforLB would have a very different tone and aim.

In considering Southern Health’s actions since Connor died and looking through Southern Health’s Board papers for 2013, however, I have come to add a fourth aim:

  • To prompt relevant organisations – statutory, regulatory, legal or otherwise – to fundamentally question and consider Southern Health’s ability to provide care services to people in the future.

I question their fundamental future fitness for purpose. This post explains (in some detail) why.

The characteristics of Southern Health’s apology

The key characteristics of Southern Health’s apology for Connor’s preventable death are as follows:

  • Deep sorrow
  • A recognition that they failed to take the necessary actions to keep Connor safe
  • A commitment to learning from the tragedy to prevent it from happening again
  • Concern that the unit Connor died a preventable death in was found to be non-compliant with a number of CQC standards
  • Working with commissioners to bring service delivery in line with the model that has delivered good results in Southampton and Hampshire
  • A number of resulting actions, including:
    • Reviewing staff training
    • An audit of all existing care plans, including ensuring the social history of a patient is included along with advice and details provided by family members and carers
    • Committing to listening to our patients and acting on their feedback
    • Looking closely at the relationship between our various learning disability teams and services to make sure they are working together to best effect.

There are some of us who are skeptical about Southern Health’s ability to appropriately follow through on these actions, and who doubt whether they will make any meaningful difference to the “care” and services “provided” by Southern Health.

Our skepticism was based on how we knew Southern Health to have dealt with everything regarding Connor’s preventable death so far. However, we have found a similar case in which Southern Health’s actions led to the death of a patient and in which their response then followed a very similar pattern to now.

Southern Health has prior

Hannah Groves was 20-years-old, had made two suicide attempts in three as well as attacked her mother and brother, and had been noted as suicidal by a trainee doctor. Treatment had been requested in October 2012 at Antelope House, a specialist mental health unit in Southampton run by Southern Health. No assessment or treatment was forthcoming, and on 22 October 2012 a member of the mental health team at Antelope House described Hannah as a “fucking waste of time” and “an attention seeker”.

Hannah committed suicide, and was found dead later that day.

The Coroner, in September 2013, delivered what was described as a “damning assessment” of Southern Health’s actions in the days leading up to Hannah’s death. It was noted that the increasing risk to Hannah’s safety was “not adequately identified” and there was “at all stages a failure to appreciate the extent of the risk that Hannah was at” and to realise “a wholly impossible stage had been reached and that for however a modest period of time Hannah required hospital admission and care”.

The key characteristics of Southern Health’s public apology for Hannah’s death were as follows:

  • Sincere apologies
  • Admitting liability for Hannah’s death
  • A commitment to learn from the experience and ensure that similar incidents are avoided in the future
  • A number of resulting actions, including:
    • Ensuring staff have further training
    • Working more closely with relatives and carers to ensure their concerns are actively considered as part of care-planning and risk assessment
    • Improving the way care is coordinated between individuals and teams.

Looking at the minutes of the Board meeting of 10 September 2013 (paragraph 7.2 , pp.7-8) we also see that Southern Health:

  • Provided assurance that immediate actions identified in a dedicated action plan for Antelope House had been undertaken, and confirmed that the actions required would be completed by the Trust by the end of October 2013
  • Noted that in Hannah’s case the Trust had “missed the opportunity to take adequate account of the views of the family”
  • Noted “it was critical for a single lead for an individual’s care”
  • Sought assurance of what had changed as a result of the learning from this event, which included “new senior clinical leadership within the Southampton area, and that work was underway to improve capabilities within teams for effective risk assessment”.

Now, it only takes a casual glimpse to see that the things Southern Health said they would put in place following Hannah Groves’s (preventable) suicide are almost identical to the things Southern Health have said they are putting in place following Connor’s preventable death.

The question we should ask, then, is what difference did these things make after Hannah died?

Taste the difference?

Whilst Southern Health were publically confident that “the transformations made during the last nine months” at Antelope House meant they were better able to support people there, the Board minutes note that:

Work had commenced [on the resulting action plan] from October 2012; [the Acting CEO] expressed concern that the Board had not received adequate assurance of these actions, and suggested that further information and assurance be provided via Quality & Safety Committee in order to monitor this, and provide upwards assurance to the Board. [The] Non-Executive Director and Chair of the Quality & Safety Committee, endorsed this approach, and requested a full discussion at the next Committee meeting [14 October 2013], with the appropriate information available. [The] Chairman concurred, and requested that the Committee provide assurance to the Board that the action plan was robust and implemented appropriately.

Note that this is fully 12 months after Hannah Groves died.

In the summary note of the Quality & Safety Committee meeting of 14 October 2013 (paragraph 2.1.2) it is noted that

Significant work had been undertaken to implement the agreed actions, including a review of the clinical leadership within the team.

Similarly, in the full meeting minutes of the 14 October Quality & Safety Committee meeting the following is included:

[It was] noted that in addition, attempts were always made to involve the family and carers [in Critical Incident Reviews] (para 6.3)

and

[Committee member] asked for assurance as to whether the identified actions would prevent reoccurrence of a similar issue. [Executive Manager] confirmed that there were a number of elements within the action plan, which would help to prevent a similar issue occurring (para 6.5)

and

[Committee Member] questioned the strengths of staff at appropriate risk management. [Executive Manager] noted that a programme of work was underway to improve the processes for the management of complex clinical risk, including tailored training for clinical staff (para 6.6).

What this tells us, then, is that Non-Executives sought, and were given, reassurance that the things they expected to be in place were indeed in place.

For a moment, then, let’s take all of this information at face value: there had been a serious incident arising from inaction at Antelope House in October 2012, but a comprehensive action plan was put in place to address the issues highlighted.

What, then, did the CQC have to say about Antelope House when they inspected it on 1 August 2013 (pdf)? Of the 8 areas inspected, 6 met the required standard, but 2 – care and welfare of people who use services; and medicine management – needed action. So, two areas were not compliant with the CQC nine months after Hannah Groves had died.

What happened when the CQC did a follow-up inspection on 2 December 2013 (pdf)? Three areas were not compliant with the CQC; one of which required enforcement action. Which one? The care and welfare of people who use services – one that had already been identified as “needing action” 4 months before.

That is, the state of the service at Antelope House had demonstrably got worse, despite the assurances of the Executive Team that suitable actions were in place.

When considering the characteristics of Southern Health’s apology in the case of Hannah Groves, then, we can see the actions they took made no difference.

What does this mean for Connor’s care?

For each of the commitments Southern Health made as a result of Hannah Groves’s (preventable) suicide, what can we say had an impact on the “care” Connor received? I’ve grouped together all of the relevant statements made after Hannah Groves died, and now look at each of them in turn.

A commitment to learn from the experience and ensure that similar incidents are avoided in the future

The fact #justiceforLB exists shows that a similar incident wasn’t avoided.

We will put in place new senior clinical leadership

As Verita’s report finds (F19) over Connor’s death: “The unit lacked clinical leadership, in particular from S1 and S3.” The new leadership at Antelope House has made things worse, not better.

Ensuring staff have further training (especially regarding appropriate risk assessment)

Verita noted that epilepsy was not part of Connor’s risk assessment and that, despite it being known Connor enjoyed taking long baths, no specific risk assessment was undertaken on this topic. Furthermore, according to the CQC, Southern Health 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, some two months after Connor died. In no way could it be said there was appropriate and relevant training in place at the STATT unit.

Working more closely with relatives and carers to ensure their concerns are actively considered as part of care-planning and risk assessment, and so not “miss opportunities to take adequate account of the views of the family”

Southern Health’s staff didn’t just not engage with Connor’s family; the report indicates they actively chose not to engage with them. For example, “Trust staff had little or no prior knowledge of [Connor], so they should have found out more about his family’s understanding of his needs” (comment after paragraph 7.11). Furthermore, there was “no evidence that the experience and knowledge of [Connor’s] parents were captured at the beginning of his admission or included as part of his risk assessment and care plan” (F13). There is no evidence at all that Southern Health staff tried to work more closely with Connor’s relatives or not “miss opportunities” to take account of their views.

Improving the way care is coordinated between individuals and teams, including it being “critical for a single lead for an individual’s care”

Verita found that the unit “caring” for Connor “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.” Something Southern Health’s own board noted as “critical” wasn’t in place.

Provided assurance that immediate actions had been undertaken, and confirmed the actions required would be completed by the Trust by a certain date

As we’ve noted, the service that failed to prevent Hannah Groves’s suicide got demonstrably worse, despite the assurances of the Executive Team that suitable actions were in place.

Summary

There is a saying which suggests: “Once is an accident, twice is a coincidence, and three times is a pattern.”

Following the (preventable) suicide of Hannah Groves, Southern Health’s Cheif Executive and Executive Managers 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.

I don’t think any assurances provided by Southern Health about what they will learn and do in the future can be trusted.

It is for this reason, built on all of the details presented above, that I call to prompt relevant organisations – statutory, regulatory, legal or otherwise – to fundamentally question and consider Southern Health’s ability to provide care services to people in the future.

(For more information about #justiceforLB, the summary is here and all information and reaction on Twitter is channeled through @JusticeforLB.)

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On Southern Health and Connor Sparrowhawk’s preventable death #JusticeforLB

Connor Sparrowhawk – or Laughing Boy, LB, as his mum called [1] him on her blog – died in the ‘care’ of Southern Health NHS Foundation Trust at their Short-Term Assessment and Treatment Team (STATT) unit on 4 July 2013. That is, an 18-year-old died [2] whilst in an institution specifically designed, commissioned and paid to support him and keep him safe.

An independent inquiry by Verita into Connor’s death was published on 24 February 2014.

The conclusion of the independent inquiry is unambiguous:

“We conclude that the death of [Connor] was preventable… We found two broad areas where [Connor’s] care and treatment had failed significantly: his epilepsy care and the overall care provided by the unit.

“The failure of staff at the unit to respond to and appropriately profile and risk assess [Connor’s] epilepsy led to a series of poor decisions around his care – in particular the agreement to undertake 15-minute observations of his baths. The level of observations in place at bath time was unsafe and failed to safeguard [Connor].

“… The unit lacked effective clinical leadership and they 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. The impact of this was that standalone key safety decisions such as those pertaining to bath time observations were not validated by other professional colleagues.”

Within this inquiry’s findings there are so, so many issues and questions about the ‘care’ that Southern Health ‘provided’. These have been highlighted and explored already by others, including @GeorgeJulian, @thesmallplaces, and @indigo_jo.

In the rest of this post are shared some reflections on themes of this tragedy [3] that stand out for me. Throughout, it is vital to remember that this was a unit for a maximum of seven in-patients and there were five at STATT at the time Connor was there.

Epilepsy

Southern Health demonstrated a complete lack of understanding of epilepsy.

Ask a layperson about epilepsy and they’ll mention “fits” or “seizures” and talk about driving and baths. Look at the most basic guidance from organisations like NICE or Epilepsy Action and they will tell you “around one in every four people with epilepsy has learning disabilities [and] half of all people with learning disabilities has epilepsy”.

And yet Southern Health observed Connor less frequently in the bath (every 15 minutes) than when he was just around the unit (every 10 minutes). There was no record about why 15-minute observations were considered to be appropriate. The practice that Southern Health had written down was unsafe – e.g. waiting 10 minutes to contact emergency services if Connor experience a seizure, when NHS advises this should be no more than 5 minutes. They ran out of epilepsy medicine on 30 March. Only 3 of 17 members of unit had had epilepsy training between October 2010 and August 2013. Worse, S11, who undertook one of the first risk assessments of Connor when he was admitted to the STATT, had attended epilepsy training on 13 February 2013 (paragraph 6.76), i.e. just five weeks before Connor was admitted to the STATT.

There was a complete lack of engagement with Connor’s epilepsy and its relevance to his presence at the unit. There was no epilepsy profile, no medical review, no comprehensive care plan, no epilepsy pathway in operation in Oxford, and epilepsy was not part of Connor’s risk assessment. It was known that Connor enjoyed taking long baths, but yet no specific risk assessment was undertaken on this topic.

There was contradictory information about whether Connor had recently had a seizure. In parts of their ‘care’ of him, Southern Health thought he was seizure free, and yet had done at least two things that indicated they thought he had had a seizure whilst at the unit (epilepsy sensors and moving Connor to a downstairs bedroom).

Staff and ‘leadership’

One (S14), possible two (S14 and S5) could be seen to have been doing their job and possibly something beyond that during Connor’s time at the unit. Everyone else was not just not doing their jobs, but actively seeming to not be doing it. In concluding that Connor’s death was preventable, Verita note that staff at the unit had both the knowledge (paragraphs 6.81-6.83) and the opportunity (paragraph 6.84) to stop his death happening.

Consider the sheer number of people involved in Connor’s ‘care’, and yet no comprehensive assessment or plan was put in place. At a short-term treatment and assessment unit, there was nothing short-term about it, there was little treatment beyond medication and there was insufficient assessment done [4]

There was no clinical leadership at the unit – not just relating to Connor (though this is obviously most important in this case) but to everyone. There is no identifiable responsibility, accountability or professional conduct.

S1 and S3 are particularly shameful in their behavior [5].

Paragraphs 6.45-6.46 demonstrate, in S1, someone who takes absolutely no personal responsibility for what happened.

“What I’m telling you is yes, I was involved at that time, yes, I had knowledge of all those development, yes, I was party to those conversations, but it’s not the case that at any point in that particular instance I was required to say well I think this…”

Paragraph 9.24 sees S1 sharing more thoughts on what they thought their responsibilities weren’t:

“What you’re asking me is if there is any central document where everything is put together; 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.”

Finally, paragraph 9.36 shows the pressures S1 was working under:

“It certainly threw me. It threw me out of my stride, I didn’t know what was happening and it took me a while to recover from it.”

This, remarkably, is S1’s description of a CPA meeting that didn’t follow the “set format”. (S4 shared S1’s disquiet: “[I]t seemed that this was becoming a person-centred meeting” (paragraph 9.41). Heaven forfend!)

Actually, what these quotes show is senior clinical leaders who have no grasp of anything happening within their own unit.

S3 – whose engagement with the whole situation is an embarrassment to any professional and, frankly, negligent (see “engagement with the family” below) – didn’t follow up on basic actions agreed at the Clinical Team Meeting of 24 June (paragraphs 8.8 and 8.9).

Finally [6], Connor probably should never have been at the unit in the first place; what’s worse, at least two professionals – our friends S1 and S3 again – thought he should have been discharged but took no personal responsibility, despite being in positions of authority, to do so (paragraphs 10.8 , 10.9 and 10.16). Page 81 of the report is the first place where any mention of Connor’s possible discharge from the unit is mentioned.

As Verita’s report finds (F19):

“The unit lacked clinical leadership, in particular from S1 and S3.” [7]

(See also @ChrisHattonCEDR’s post on Bystander Apathy).

Engagement with the family

The first mention of Winterbourne View [8] in the report relates to the Department of Health’s report into that scandal, noting that “families were often not involved” in the care of their family members, and that this “is sadly a common experience and totally unacceptable” (paragraph 7.2).

Southern Health’s staff didn’t just not engage with Connor’s family; the report indicates they actively chose not to engage with them. For example, “Trust staff had little or no prior knowledge of [Connor], so they should have found out more about his family’s understanding of his needs” (comment after paragraph 7.11). Furthermore, there was “no evidence that the experience and knowledge of [Connor’s] parents were captured at the beginning of his admission or included as part of his risk assessment and care plan” (F13).

Actually, Southern Health staff’s approach to the family was adversarial. Read in paragraphs 7.17-7.18 how S3 talked to the family about whether they could visit or not; read in paragraph 7.19 what S3 had to say when Connor’s younger brother wanted to visit the person he’d shared a room with for his whole life; read in paragraph 7.20 how a member of staff lied directly to Connor’s parents about whether Connor wanted them to visit; read also in paragraph 7.20 how S3 thought (a) it was reasonable to put am 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; read in paragraph 7.31 how S3 reduced an experience Special Educational Needs teacher to a distressed state through their interrogations.

But this isn’t just a question of tone. The most crushing element of the impact of unit’s staff deliberately sidelining Connor’s parents is paragraph 6.60 – that Connor’s family would “supervise him, keeping the door open and talking to him” when he was in the bath; that there was “no evidence that staff knew about the way [Connor’s] parents supervised his bathing”. That staff had no idea how his parents had kept him safe to date [9].

Southern Health

Where to start with Southern Health as an organisation? Let us begin with what the Verita report has to say directly.

Paragraph 2.4 notes that Southern Health has a range of policies and guidelines that provide the framework within which their ‘care’ is provided. Throughout – see paragraphs 5.29, 5.32, 5.56, 5.60, 5.70, 6.3-6.5, 6.13, 6.17, 6.29, 7.5, 8.11, 9.20 – we see that this paperwork was only that, paperwork.

Staff interviewed by Verita, as part of an inquiry into the death of someone in their ‘care’, hadn’t been given relevant paperwork, such as the guide for interviewees and the terms of reference, before their interview. This is surprising, because events during the Inquiry (on which more later) would suggest that Southern Health’s main concern in the inquiry phase was its own reputation and protecting its staff.

Most damagingly, Verita received “substantial additional documents” relating to the review (paragraph 4.9) on Weds 19 Feb – less than three working days before the report was published, after the draft report had been sent to Southern Health, all relevant people and Connor’s family. What were these documents? Why were they sent only then? (See FOI request later)

(We must also ask: where are commissioners? The only mention I can see in the report of local authority commissioners is in paragraph 11.15; no mention I can see is made of the relevant Clinical Commissioning Group (CCG).)

CQC inspections

Now let us consider what the statutory regulator of health and social care services had to say of Southern Health.

The Care Quality Commission visited the STATT Unit on 16, 17 and 23 September 2013, two months after Connor died. Their first inspection found that the Unit was not compliant in any of the 10 standards. Of the 10, 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.

The inspection report notes the following:

People did not always experience assessment, care, treatment and support

Remember, this is in an assessment and treatment unit.

“Whilst we were there, up to four staff mainly worked on administrative tasks within their office… There appeared to be an impoverished environment with little therapeutic intervention of meaningful activities to do.

Assessment and Treatment Units cost, on average, £3,500 per person per week.

[T]he emergency oxygen was significantly out of date… We inspected the emergency equipment [the defibrillator and oxygen cylinder], and found some of it wasn’t working.

The equipment wasn’t working because there was no battery in the defibrillator, and the oxygen cylinder was out-of-date. Remember, this is two months after someone had died at the unit in circumstances that are likely to have required both a defibrillator and oxygen.

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.

Paperwork.

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[.]

Again, remember this is two months after a lack of appropriate risk management led to a preventable death at the unit.

By 16 December, a follow-up inspection by the CQC found three of the areas that required enforcement action had met the standard. These were (a) Cleanliness and infection control; (b) Safety and suitability of premises; and (c) Safety, availability and suitability of equipment. I.e. those actions that required practical changes only, rather than cultural or attitudinal ones

All CQC reports on STATT can be found here.

Verita’s report

Verita should be congratulated on an excellent and rigorous independent report into the circumstances of Connor’s death. People familiar with the language of Serious Case Reviews and similar inquiries will note the obvious difficulties that Verita had with Southern Health in bringing together this report. For example, paragraph 1.12 notes they were “directed by the trust” to put in place anonymisation in the report that “makes it difficult to read”. Similarly, paragraph 4.2 notes that some interviewees for the report didn’t receive relevant paperwork before they were interviewed.

Questions, questions and Freedom of Information

Verita’s report covers the period until 4 July 2013. Notwithstanding any criminal investigation by the police, any professional standards investigation by any representative body, or any Southern Health staff disciplinary proceedings [10], in my view, there is need for a second inquiry into Southern Health’s actions after 4 July, inquiring into a range of issues. Those issues include, but aren’t limited to:

  • Their initial response to Connor’s death
  • The steps they have taken with regard to staff involved in the unit
  • Their relationship with organisations that commission their services
  • Their engagement with Connor’s family following his death
  • Their actions in relation to the commissioning, interviewing, drafting and publication (including permission to publish) of Verita’s independent inquiry
  • Information relating to any public relations or communications advice they have received since 4 July.

Freedom of Information requests will be submitted to Southern Health to explore these issues.

#justiceforLB [11]

(For more information about #justiceforLB, the summary is here and all information and reaction on Twitter is channeled through @JusticeforLB.)

Notes

These additional notes have been separated  from the main body of the post above because they are personal reflections only.

[1] – Past tense. In the minutiae of the death of a loved one, these small things are, to me, the most terrible. I will be able to kiss my children tonight, to speak with them. These opportunities have been taken away from Connor’s family.

[2] – When does “died” become “manslaughter” becomes “killed”?

[3] – “Tragedy” implies something inevitable. We know what happened to Connor, as we know what has happened to hundreds of people who have died by indifference in ‘care’ settings before. What, therefore, of calamity, devastation, evasion, abandonment, dereliction, neglect, crime?

[4] – STATT didn’t do what it said on the tin. It did nothing.

[5] – Collective noun for staff at Southern Health: “An abandon of S’s”.

[6] – What if? what if…

[7] – What disciplinary action will S1 and S3 face? Will they be referred to their professional bodies?

[8] – “Post-Winterbourne”. We’re not post- anything.

[9] – What of those people who don’t have family, or advocates, or people who can look out for them, and speak for them if they wish? What of them?

[10] – Yeah, I know.

[11] – What could “justice” possibly mean?