Not learning lessons – the Southern Health way

A year ago, Ally Rogers, LB’s cousin completed her dissertation looking at the communication style of Southern Health I wrote 11,962 words on Southern Health’s crap communications so you don’t have to. Today a post detailing an update of this work, and the continued poor communications, is published on the Open Democracy blog. It’s definitely worth a read of Ally’s post in its entirety but in case you’re short on time, this is the headline of what it is about:

I’ve been looking at the language used in statements surrounding these events [failings at Southern Health] and I’ve spotted some features that pop up repeatedly, such as suggesting ongoing change, a focus on staff rather than patients, repetition of the curious phrase “not always good enough”, and the non-apology.

Not surprisingly, Ally’s analysis sounded familiar to those of us in the Justice Shed and it overlapped with the experiences of many families who have been on the receiving end of Southern Health’s ‘not always good enough‘ care.

A month or so ago Richard West appeared on the Victoria Derbyshire show. He was asked to speak about failings in mental health care and he shared what had happened to his son, David. You can watch a clip from the show featuring Richard here:

In his interview Richard introduces David, explains what happened to him, how he became aware after his death that there was something wrong with David’s treatment, and he also references the report into his complaint published by the Parliamentary and Health Services Ombudsman.

The PHSO report describe’s Richard’s complaint as follows:

Mr West said he felt the Trust had failed his son, and opportunities had been lost to reduce the risk of him coming to harm. He said he accepts his son may well have died at some point anyway due to his drug addiction problems, but without the right care the chances of things going wrong were higher. Mr West also said the Trust’s responses to his complaint had left him confused and distressed, and he had had to push for answers which had been ‘wearying’.

Having investigated Richard’s concerns, and Southern Health’s response to David’s death, the PHSO upheld a number of the complaints that Richard made:

We have found failings in the care provided to David West. These include:

  • failing to allocate a care coordinator
  • failing to refer to Assertive Outreach or for a forensic assessment
  • not following relevant national guidance
  • not updating Risk Assessments and Crisis, Relapse and Contingency Plans
  • writing unprofessional and derogatory comments within medical records
  • discharging from mental health services against the Trust’s own policy on patients who do not engage or fail to attend appointments
  • discharging from the Community Treatment Team and not communicating this decision
  • failing to fully consider adult safeguarding policy
  • failing to assess the need for aftercare under section 117 of the Mental Health Act 1983

The failings we identified in David West’s care meant some opportunities to treat his mental illness and limit his deterioration were lost. This meant Mr West has been left not knowing if the outcome could have been different if his son had received better care.

Although the Trust has taken some action to put things right we believe it needs to do more to resolve the complaint. The Trust has not acknowledged the full extent of the failings in David West’s care and treatment.

We saw some failings in the Trust’s handling of Mr West’s complaint. Some of the findings of the Capsticks report [the Trust’s response to Richard’s complaint] were not aligned with the earlier findings of the Critical Incident Review (CIR), but these differences were not explored and explained in any detail in the Trust’s complaint response letter. This caused confusion and further distress to Mr West. The Trust also failed to act upon and investigate issues Mr West raised in a letter to the Trust Chairman and Non-Executive Directors in July 2014. These failings in complaint handling led to Mr West suffering additional and unnecessary distress.

Here we are, 2.5 years after David died, almost three years after LB died with Southern Health still failing to acknowledge the full extent of their failings. Ally’s work clearly shows how little they have learned, and how unprepared they are to take responsibility. When the Mazars report was published back in December, Katrina Percy, the CEO at Southern Health had this to say:

“We apologise to anybody who feels let down by any aspect of our service.”

Over to Ally…

Let’s break this down: the use of “anybody” rather than “everybody” suggests doubt that anyone needs an apology at all, and the focus on ‘feels’ in “anybody who feels let down” suggests that an apology is necessary only if you felt let down.

In one small sentence, Katrina Percy not only casts doubt on the idea that anyone does in fact have an issue with Southern Health but then puts the responsibility for this feeling on to the people themselves.

Tomorrow afternoon at 2:30pm Richard’s MP, Suella Fernandes, will lead a Parliamentary Debate (info and papers here) about the Governance of Southern Health NHS Foundation Trust. She told the Daily Echo that MPs ‘have expressed serious doubts about the governance of the Trust, and remain to be convinced that the necessary improvements are being made quickly enough’. Tonight the Justice Shed is a heady mix of optimism and hope, tempered by nagging doubts of the reality to date, we’re not convinced either but hope that a robust debate will lead to some actual progress and accountability.

2 responses to “Not learning lessons – the Southern Health way”

  1. Dear All.
    I am so sorry for your losses. I also lost my son under care of a mental health trust in Essex . Namely the North Essex Partnership Trust.
    I have proved failings in care. Inadequate safety ratings with cqc. Action plans not actioned. Falsified care plans. No care plans. No rusj assessmenrs.. Unnecessary deaths.
    Most of board have now resigned.
    Not one person has been held to account. It’s sickening what’s happening to our loved ones. A local councillor put it to me that a menral health patient who was not working cost society on average €100,000 per year with ambulance and police call outs so better to let them die so budgets could be sorted and reduce overheads. It made sense.
    I really hope you get somewhere with accountability..and I’d like to know how you do when you do…ands ill do the same but each board member that resigned to date just merrily moved on to new high pay jobs within the nhs..ready to do the same again. It’s criminal.

  2. […] 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 […]

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