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?

“Never do anything by halves if you want to get away with it…”

How can she get away with it?” Lavender said to Matilda. “Surely the children go home and tell their mothers and fathers. I know my father would raise a terrific stink if I told him the Headmistress had grabbed me by the hair and slung me over the playground fence.”

“No he wouldn’t,” Matilda said, “and I’ll tell you why. He simply wouldn’t believe you.”

“Of course he would.”

“He wouldn’t,” Matilda said. “And the reason is obvious. Your story would sound too ridiculous to be believed. And that is the Trunchbull’s great secret… Never do anything by halves if you want to get away with it. Be outrageous. Go the whole hog. Make sure everything you do is so completely crazy it’s unbelievable. No parent is going to believe this pigtail story, not in a million years. Mine wouldn’t. They’d call me a liar.”

[…]

“I don’t think she’s mad,” Martilda said. “But she’s very dangerous.”

– from Roal Dahl’s Matilda.

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

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.)

Congratulating Southern Health (and fisking them), and true leadership #justiceforLB

There has been a remarkable level of interest in #justiceforLB. I say remarkable; it’s perhaps more a natural reaction to the even more remarkable fact that Connor Sparrowhawk – a brilliant 18-year-old, son, brother, friend – died a preventable death in the “care” of an institution run by Southern Health that was specifically designed, commissioned and paid to support him and keep him safe.

To get a sense of it all [of course, there is no “sense”; how could there be?] please follow @justiceforLB or the hashtag #justiceforLB.

Today has seen more media activity in specialist press, local news and some interest from national organisations, which is great. It’s nowhere near enough when it comes to what needs to happen and what needs to change, but it’s a start.

And what of Southern Health? In a way, they should be congratulated for their work on the comms and PR side of things. I say this because you may not have thought it was possible for them to be any worse than they already have been at any point throughout this whole situation. The depths they have plumbed have been quite astonishing (quite aside from, y’know, their being responsible for the preventable death of Connor). And yet today they have surpassed even themselves through shameful and callous acts in responding to (or not) public interest in what happened to Connor.

When it couldn’t get any worse, Southern Health somehow found a way. For that, we should congratulate them.

Here I’ll focus on just two elements of Southern Health’s continued exploration of depths to which nobody could ever believe they would sink, though please do share your own thoughts, too (#justiceforLB).

1. Leadership

The first element is that the Chief Executive of Southern Health – someone who has won an NHS Leadership award for her “style of leadership that engenders self-motivation among staff” [did someone tell S1 and S3?] – is nowhere to be seen. Sure, her name was attached to Southern Health’s press notice about Connor’s death, but, erm, that’s it. Instead, the person left to represent Southern Health in the media is their Deputy CEO.

Now, I’m no expert on leadership but I’m pretty sure it has something to do with personal accountability and responsibility, and being present when something bad has happened, as well as the good times.

Am I alone in thinking that NHS Leadership Award standing on the mantelpiece at home is looking a bit hollow?

Alas, the only true leadership we’ve seen has been from Connor’s mum, Sara / @sarasiobhan, who is the one being dignified, balanced and impassioned (on Radio 4 (27 mins in) or BBC Oxford (1hr7m in)).

True leadership, despite the fact her son died.

2. Southern Health’s media lines

The second element is the lines that Southern Health have agreed for their press activity.

A media briefing will obviously have been put together for their Deputy CEO. Using their appearance on BBC Oxford News last night and BBC Oxford radio this morning (links here and here respectively, video/audio to follow) let’s explore the key aspects of that briefing.

1. We want to use the findings of this report to improve our services right across the Trust.

The service didn’t meet a single one of the 10 standards inspected by the CQC, 8 weeks after Connor died. You were issued with six enforcement action notices. There were fundamental failures of the most basic nature in the “service” and “care” that was being provided by Southern Health.

Would one of your proclaimed “improvements” be “don’t leave people with epilepsy unsupervised whilst taking a bath?” – the sort of advice any member of the public could give?

And yet the independent investigation found that Southern Health had policies, guidance and pathways in place that should have ensured there were minimum standards of care, but that all of these were simply paperwork, and didn’t translate at all into practice. There were staff actively not engaging with family members. For Connor, 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.

You’re fortunate that “improve” is a relative concept, because it’s the only way to accommodate the fact you provided the most fundamentally flawed and inadequate service possible.

2. We’ve asked ourselves “Why was it the CQC found things in our services that we should have found ourselves?”

And what answer did you reach? At what point did it not occur to you to undertake a risk assessment regarding someone with epilepsy taking a bath? When did it seem reasonable for members of your staff to be “thrown off their stride” because a meeting about someone in their “care” was in danger of being person-centred? Who have you found responsible for this failing? How are you not awake every single night thinking about the preventable death you failed to prevent and who else is in danger across all of your services?

3. We experienced delays in our response, in part because of the role of the police.

The police? Someone dies in one of the units you run – where only 4 other people were being held, in a place designed only for 7 people anyway – and you don’t consider changing one thing until the police have looked at the circumstances? Even then, were the police looking at this for 8 weeks, i.e. the time since Connor died and the CQC visited?

4. We can sympathise with Connor’s mum’s position.

Can you?

5. We’re deeply sorry this has happened.

Are you? Because you’re doing a pretty fucking good job of appearing very insincere in your sorrow.

6. We commissioned an independent investigation.

This was after you’d tried to dismiss Connor’s death as being of “natural causes”, of course.

But, anyway [anyway? Jesus], let’s look at your support of that independent investigation, shall we?

Staff interviewed as part of the investigation inquiry weren’t given relevant paperwork before their interviews. The investigators received substantial additional documents relating to their investigation less than three working days before the report was published, and after the draft report had been sent to you. You insisted the report was redacted to such an extent that it is virtually impossible to determine who did what and when [“we are able to publish a final copy of the fully redacted report. We are of course very pleased about this as it allows a spirit of openness and transparency.” Jokers.]. When Connor’s family appointed an advocate to support them throughout the investigation, you tried to have them removed, citing the most circuitous conflict of interest it’s possible to imagine. You appointed external solicitors. You didn’t commit to making the report public until days before it was due back from the investigators. You published the report at 5.45pm on the day of publication, citing the need for “written permission”, from whom we still do not know.

You may well have commissioned an independent investigation, but you did your damnedest to obstruct the process and publication of that investigation.

7. We want to do anything we can to help Connor’s mum “move on”.

What you mean to say is you want Connor’s mum, and everyone else, to “move on” and leave you alone.

Well, I’m afraid we won’t.

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