Bunker mentalities and stubborn denial #JusticeforLB
Today a debate requested by Suella Fernandes, MP (on behalf of Hampshire and Oxfordshire MPs with constituents under the ‘care’ of Southern Health) took place in Parliament. It was called to consider the issue of governance at Southern Health. You can read the transcript of the 90minute debate on Hansard here.
The failings at Southern Health have been well documented on this blog and elsewhere, so we wont revisit them here, but the independent reports that point to failings include two by Verita, the Mazars report, two PHSO reports (one into David West’s death and one into Jo Deering’s), numerous CQC reports and most recently NHS Improvement placed an additional condition on Southern Health’s licence to provide NHS services. Many of these failings were referenced in the debate:
Suella Fernandes: Time and again, in report after report, Southern Health has been criticised for its failures of management and leadership, and the effects that those failures have had on the care that it provides. That is why I called for this debate that focuses on the governance of the trust. We all accept that, sadly, tragic failures in care will inevitably occur from time to time, and those at the top of an organisation cannot held be responsible for every incident on the frontline.
Equally, we must pay tribute to the dedicated staff of Southern Health for the excellent care that they give day in, day out for the majority of the time. We cannot and should not tar all of them with the same brush because of the failures of others. However, when clear and systematic problems have been identified, we are entitled to ask that lessons be learned. For me, the most shocking part of the sequence of events that I have just recounted is that right up until this year—indeed, even in the last couple of months—inspectors have stated that necessary changes that have been flagged up as needing action have not been implemented.
When NHS Improvement said in its enforcement notices that the trust was failing in its obligations under its licence and did not have effective border capacity and capability, it used the present tense. That was in April.
In this post we wish to highlight what was said about the leadership at the top of Southern Health. This is done through a series of quotes:
Suella Fernandes: It stated that there had been warnings about the standard of care in facilities including Slade House, and criticised the management processes following the transfer of services to Southern Health…
The report [Verita 2] concluded: “Southern Health should have ensured that any deterioration in the quality of services could be identified quickly and by processes that Southern Health had confidence in.” That was the first serious criticism of the overall management of the services.
Mims Davies detailed concerns that her constituents had raised with her, and that they would rather cope at home than rely on Southern Health services.
Suella Fernandes: The report [Mazars] was published in December 2015, and its main findings included, first, that many investigations into deaths were of “poor quality” and took too long to complete. Secondly: “There was a lack of leadership, focus and sufficient time spent in the Trust on carefully reporting and investigating…deaths”. Thirdly, there was a lack of family involvement in investigations after a death and, fourthly, opportunities for the trust to learn and improve were missed… The Mazars report contained serious and specific criticisms of the trust and its management. In particular, it levelled criticism at the board itself for the failures. It found that “there has been a lack of leadership, focus and sufficient time spent on reporting and investigating unexpected deaths of Mental Health and Learning Disability service users at all levels of the Trust including at the Trust Board.”
Andrew Smith said what so many of us have asked:
In just about any other organisation, such a searing indictment of the board and, by implication, its executives would have resulted in their resigning. Is she surprised that they did not simply stand down and accept responsibility, as they should have?
Fernandes returned to the failings in Mazars, raising the Board failures and the ignoring of repeated warnings by Coroners. Kit Malthouse raised the issue of the lack of specificity or deadline in the supposed improvements being made. Fernandes returned to the failings documented by the CQC and NHS Improvement/Monitor.
On the wider issue of reporting deaths, the [CQC] inspectors found that the trust did not operate effective governance arrangements to ensure robust investigation of incidents, including deaths; did not adequately ensure that it learned from incidents, so as to reduce future risk to patients; and did not effectively respond to concerns about safety that had been raised by patients, their carers and staff, or to concerns raised by trust staff about their ability to carry out their roles effectively.
All those findings, and the serious step of issuing a warning notice, reinforce the most serious of the Mazars findings. Dr Paul Lelliott, the CQC’s deputy chief inspector of hospitals and lead for mental health, was quoted as saying that the services provided by Southern Health required “significant improvement”. He said: “We found longstanding risks to patients, arising from the physical environment, that had not been dealt with effectively. The Trust’s internal governance arrangements to learn from serious incidents or investigations were not good enough, meaning that opportunities to minimise further risks to patients were lost. It is only now, following our latest inspection and in response to the warning notice, that the Trust has taken action and has identified further action that it will take to improve safety”.
Malthouse raised the frustration that no-one appeared to take personal responsibility for the failings at Southern Health. Fernandes replied:
I find it difficult to have confidence that she [Katrina Percy, Southern Health CEO] has properly acknowledged the scale of the problems under her leadership or how difficult it will be for patients and families to have their faith in the organisation restored without a visible sign of a fresh start.
Resignations are a matter for individuals, and Katrina Percy has said that she believes her responsibility is to provide stability by remaining in post. I understand that position, but the sheer weight of criticism of the trust’s leadership over a prolonged period while she has been chief executive would lead many to a different conclusion. The fact that NHS Improvement has now taken the power to direct changes at board level if it considers them necessary sends its own message.
Mims Davies again raised the lack of confidence in the leadership at Southern Health:
It has been my perception that there has been a sort of bunker mentality. Perhaps people are just burying their heads, going through the process and hoping it will go away. Does my hon. Friend agree that there is perhaps a little sense of that pervading Southern Health from the top?
Suella Fernandes: My hon. Friend is insightful in her observation, although I do not think it takes a genius to point it out. The catalogue of criticisms and failings is not new to anyone. I can understand the frustration and anger of families and patients when they feel that no substantive and material action is being taken.
Andrew Smith, the MP for LB’s family, added his voice to the debate. Referencing the absolute struggle that getting this far had been, he pointed out that for all the promises Southern Health were behaving as appallingly today as they had done up until now:
The facts that have emerged are awful beyond belief and are a shocking indictment of the leadership of the Southern Health trust and the appalling neglect of the most basic care needs and human rights of learning-disabled people.
As the hon. Lady said, we all owe enormous thanks to the courage and determination of Connor’s mother, Sara Ryan, and her family, as well as the other families of those who have died and suffered. Without them, there was a real risk that the hideous truth of neglect at Southern Health might not have been fully exposed. Connor’s family and other families have been let down so badly and shamefully by Southern Health, which did not share information that the family had a right to. The family were treated as the enemy at Connor’s inquest and did not even receive an apology until Southern Health was directly pressed to give one. Even today, as Sara went for mediation with Southern Health on her human rights case, it had not released background papers, as it was supposed to have done…
..it is unbelievable that the chief executive and medical director of Southern Health are still in post. We all understand that due process has to be followed, but nearly three years on from Connor’s death, we must ask: how long will it take before those responsible are properly held to account? That is important not just to atone for a wrong; it is crucial because of the signal it sends to others responsible for the care of learning-disabled and other vulnerable patients. It is crucial in re-establishing public confidence that those leading the provision of care are responsible and are held responsible for their actions
Then Julian Lewis contributed to the debate. He acknowledged that he had been somewhat reluctant to do so as he hadn’t been involved with the recent issues, however, he has history with Southern Health:
My hon. Friend the Member for Eastleigh (Mims Davies) said in her intervention that she detected something of a “bunker mentality”. She is absolutely right. The mentality that I detected at that time  was a culture of stubbornness and denial about whatever it was that Southern Health wanted to do, irrespective of what other people might wish it to do… When I made these remarks in public, Katrina Percy took objection to them and sent a letter to Ministers, councillors and Hampshire MPs denouncing my comments as “unfounded”, “scaremongering” and with “no place in the 21st century”… The difficulty that I had at the time in trying to save the beds was that the trust’s clinical director, Dr Lesley Stevens, was determined to go on repeating figures over and over again that there were between 20 and 30 beds vacant at any one time. There were not…. I believe a change of culture is needed in the trust… I hope that that lesson from the past will be borne in mind in future restructuring of the trust. I called the trust’s culture one of stubborness and denial. That may lie in the minds of individuals, rather than in its structure, but that is a matter for people other than me to decide.
Luciana Berger acknowledged the commitment of the families who had battled for justice for the deaths of their loved ones, she drew parallels to Hillsborough and she offered a stronger position on the leadership failings at Southern Health:
We have also heard about the reports on Southern Health that have demanded changes and improvements to patient safety—improvements and changes that, by and large, the trust has failed to implement over far too many years. I believe it is a story of chronic management failure. Most astonishingly of all, it is a story of a chief executive who remains in post despite this litany of failures on her watch over a number of years. I cannot imagine a chief executive in any comparable organisation who would still be in post with such a record. I take a different view from the hon. Member for Fareham and the Minister: I do not say this lightly, but I do not believe that Katrina Percy should still be in post….
We all understand that the NHS is a vast, complex institution. It deals with 1 million patients every 36 hours and employs more than 1 million people. Of course human error and tragic mistakes cannot always be prevented, but the lesson of Southern Health is that sometimes things go beyond human error. They can escalate to catastrophic levels of systemic failure, preventable deaths and cover-ups; they can descend into a culture of denial and secrecy; and they can end up at the opposite end of the spectrum of decency and compassion that characterises so much of our national health service and the caring professionals who work for it. That is why we call for a full public inquiry into preventable deaths in the NHS, so that light can be shone, families can grieve, and justice can be done. The victims and their families deserve nothing less.
It should not be left to individual families to have to fight and fund their own efforts to achieve justice. The British public, as the owners and funders of our national health service, need to be reassured that every part of it is working to its highest standards, with the best quality of care, particularly for some of the most vulnerable people in our country.
Alastair Burt, Minister for Community and Social Care responded to the debate by situating Southern Health’s failings in wider context of NHS culture:
Nothing that an official can write on a piece of paper can adequately describe what it is like to meet and talk to families who have been involved in the sort of things that we are talking about here. This is not the first time I have had such meetings: I have had them since coming into post a year ago. It is impossible to convey simply and straightforwardly all that people feel.
What worries me most—I have said this to families in private and I say it again here—is that I hear the same things again and again. I hear about the frustration and concern about the time taken to get anything done when it has been agreed that something should be done, about the time taken to get any answers about what might be done in the first place, and about the defensiveness in the attitude of the institution being dealt with—my hon. Friend the Member for Eastleigh (Mims Davies) described it as a bunker mentality. I do not know whether it is a reflection of a professional attitude—because clinicians and others see things every day—but it is genuinely upsetting to hear people who have lost their loved ones talk about the lack of simple sympathy from those who deal with them. I have heard from enough people in enough different parts of the country to know that what I am hearing is not a one-off.
I also get distressed when I hear through the system that people can be difficult. People have every reason to be difficult, but that is not an acceptable way of describing people who are concerned and upset.
He returned to the failings at Southern Health stating:
The first duty of any care provider is to keep its patients safe. The reports of inaction, bordering on complacency, set out in the recent Care Quality Commission report were truly shocking… On 12 January, Monitor announced further regulatory action in response to the Mazars report, including the appointment of an improvement director for the trust. The CQC inspection took place in January 2016 and led to a warning notice and an announcement of further regulatory action by NHS Improvement, which were both published on 6 April 2016. On 5 May, following the resignation of the trust’s chair, Mike Petter, NHS Improvement required the trust to appoint Tim Smart as the new interim chair. Those actions were in response to the persistent failure of the trust’s senior management to address the environmental and governance risks identified by CQC as far back as October 2014…
…the interim chair has already overseen improvements to clinical governance and the trust’s response to the CQC warning notice and NHSI licensing conditions. In parallel, he has commissioned an external review of the capability of the board, which extends to executive and non-executive directors and will inform a decision on leadership by 6 July. That will give the chair, whom I met a couple of days ago, the opportunity to review current capabilities with a view to the future. It is important that he has done that.
…on the position of Katrina Percy, I need to be clear: Ministers have no authority to intervene in such matters, and nor would it be right for them to do so. I have been assured by Jim Mackey, the chief executive of NHS Improvement, that agreed processes are in place to review the performance of the senior leadership team and to make any changes that are in the best interests of patients.
…The repeated failure to complete actions is one of the things that I will come on to in answer to my hon. Friend’s questions. When people are told what to do by a serious regulator, why do they not just do it? Why do they not do it in Southern Health, but do it in other places? What is the point of accountability and what is the process whereby in other parts of public service something is demanded by a regulator—say, in the acute part of the NHS—and something therefore happens, but something does not happen if dealing with those with mental health or learning disability issues?
Mims Davies interjected to share something that those of us in #JusticeforLB have been saying for a while, and that Ally (LB’s cousin) has written about for Open Democracy today, the spin and PR focus at Sloven:
Yesterday, Mr Smart told me that his initial view on exactly this point was that the senior executive team had a focus on dealing with Southern Health’s public relations issues, and not really on the care and quality in what was being delivered. That, simply, was why there was no change.
The conversation moved on to the historic failings at Southern Health, their ignoring of Mike Holder’s warnings, and potential action by the CQC and the Police. Suella Fernandes concluded the debate as follows:
The debate is for those we have lost, those let down by the professionals, those for whom help came too late and was too little, families and relatives: more widely, it is for all those with mental illness and learning disabilities. A nation is only as humane as its treatment of its most vulnerable. We here in the Chamber have a special duty to those who depend on healthcare and support.
We hope that in the external review of Board capability that Tim Smart has recently commissioned attention will be paid to this debate, to the historic concerns raised, to the warning of Coroners. That due respect is paid to the deaths that occurred as a result of the bunker mentality and the CEO, Katrina Percy’s stubborn denial. That the focus includes the mistruths repeatedly pedalled by the Medical Director Lesley Stephens, and the PR focus of the Director of Patient Safety Chris Gordon, that led to Southern Health wasting valuable NHS resources on spin and denial, trying to sink the Mazars report, rather than engage with the learning it holds. We hope that the external reviewers will take the opportunity to meet with the Mazars team, to understand the report and what it contains in more detail. We also hope that they will meet patients and bereaved families, who live with the consequences of the Board’s neglect. There is a need to focus on the evidence of practice, not the spin and intention. Despite all of the action plans, the promises and the platitudes, LB’s family and legal team today had to attend a mediation meeting without the paperwork, because Southern Health hadn’t produced it on time – no change, no lessons learned, no respect.
Suella Fernandes ended by saying ‘I hope that the debate marks the beginning of a journey towards more justice and compassion’. We hope so too in the Justice Shed, time will tell.