Slovenly leadership – a timeline of the early years #JusticeforLB
This post seeks to pull into one place what we know about the early years of Slovenly leadership, in the run up to 2013 when LB went into the unit . It only focuses on leadership failings and it is not definitive, there are so many we’d need a book or two to cover them all. Just a small clutch of examples, offered chronologically:
1a) What happened
Back in 2011, a member of staff wrote to Katrina Percy about her concerns with regards to their failure to comply with basic health and safety legislation. Her letter concluded:
1b) Leadership response
Katrina did what Katrina does best – she passed the buck to someone else, in this instance the Associate Director of Governance. They replied acknowledging the concerns, the unfilled vacancies and the gaping hole in qualified Health and Safety Leadership. The solution was to appoint an Interim Head of Health, Safety and Security for 4 to 6mths. This man was Mike Holder, who was appointed to the post in November 2011.
2a) What happened
After three months it became clear to Mike Holder that Southern Health were acting dangerously and illegally. He told the BBC:
They didn’t see how health and safety would apply to caring for the people in their care.
“I think their record keeping in general was very, very haphazard.
“I think there are missed opportunities and as a result of those missed opportunities, someone has lost their life.”
Mike resigned in February 2012 and pointed out to the Trust that their “existing safety management systems are dysfunctional”. When asked to ‘Provide specific details of how you have not been supported in developing and implementing a Health & Safety Management Strategy that is compliant with the statutory requirements of the Health & Safety Executive’ he produced a twelve page report, listing all the failings and instances where the Trust were putting lives at risk.
I believe the Trust Board is already aware of shortcomings within existing safety management systems, given the points raised within Appendix A by XX in her letter to the Chief Executive…
At present it is my professional opinion that Health and Safety is considered an adjunct to the Trust’s core business rather and integral element of it. This assumption is based on my experience with the Trust to date, the lack of resourcing applied to the management of health and safety and information governance with regards to the maintenance of statutory records…
Information contained within Appendix D which provides an update on quality, operational and financial performance for the Trust and highlights key risks and mitigations being taken, also identifies that health and safety is not considered as an essential element of the Trusts undertaking. Other than in the context of infection control, health and safety is not mentioned within the report nor does it form part of the key performance indicators…
The Trust’s VAS statistics, high number of RIDDOR reports, the number of RIDDOR’s that should have been reported (but have not) and recent HSE intervention do I believe support this view. At the time of writing the non reporting of a number of events represents a breach of Regulation 3 and 7 of The Reporting of Injuries, Disease and Dangerous Occurrences Regulations 1995, a criminal offence which you are obliged to address.
Holder goes on to address issues around Southern Health policy, organising, planning, measuring performance, and auditing and reviewing performance. He provides further evidence of failings and highlights areas of risk that should have been addressed, and which if they had have done may have prevented subsequent deaths. Mike Holder was flagging the non-reporting and poor-reporting that Mazars highlighted four years later.
2b) Leadership response
Despite these very clear links, Katrina responded to the BBC queries earlier this year in her usual manner: crap apology, denial, spin:
Ms Percy said: “We are constantly striving to find ways to do things better and challenging ourselves to improve services across the whole organisation, as in any NHS Trust.
“All of the issues raised in the memorandum sent more than four years ago were looked into and addressed.
“Those issues in no way relate to the independent review of deaths of people with learning disabilities and mental health needs in contact with Southern Health at least once in the previous year.”
In the immediate aftermath of Mike Holder’s report and subsequent resignation, you’d have thought the Board and the Executive Team would have been focused on improving health and safety for all their existing patients, making the required changes to ensure the environment and fabric of their 500 odd buildings as safe (and ligature free), switching a focus on pressure ulcers and infection control for one considering health and safety in the broadest sense. Yet no, there were more empires to be built at Tatchbury Mount. Sloven had their eyes set on acquiring Ridgeway, an Oxfordshire Learning Disability Trust, which came with chunky plots of prime land in the university city. The pound signs blinding any faint or distant concern for patient safety.
3a) What happened
Contact Consulting were commissioned by the Strategic Health Authority because it had concerns about safeguarding, patient safety and organisational culture at the OLDT team. The report highlighted:
“a disconnect between senior leaders within OLDT and the staff delivering or managing the services in terms of the understanding of quality issues and the assurance that actions needed have been taken and are fully implemented’.
This review crucially flagged up safety issues Sloven should have keenly paid attention to given they were taking over the services.
3b) Leadership response
4a) What happened
A quality and safety review by John Stagg, interim divisional nurse conducted a quality and safety review around the same time; July – Nov 2012. This raised some issues around risk assessments, consistent practice and monitoring of services and risk management.
4b) Leadership response
An action plan was produced. Stagg had the unbelievably pertinent reflection when interviewed for Verita 2 [V2], that:
John Stagg told us that it was after the Verita report into the death of Connor and the CQC visit in September that he and Southern Health came to question some of the assurances local clinicians and local clinical managers had given about improvements to practice. He felt they might not have reflected the reality of changes. The Contact Consulting report had warned Southern Health that managers did not always properly understand the quality of the services they were managing and therefore some caution should have been applied to the information received from local managers. [V2 11:59]
…He told us that it was only after the unannounced CQC inspection in September 2013 that he and senior divisional staff realised the assurances he had been receiving were not accurate or lacked sufficient evidence. [V2 12:76]
Yes really, you need to actually get evidence of progress not just rely on beleaguered, disenfranchised staff who are highly likely to tell you what you want to hear. Sound familiar anyone?
[A document leaked in 2016 showed that Stagg identified a series of failings at STATT during that review process. These were mirrored in the September 2013 CQC inspection after LB’s death.]
5a) What happened
Sloven acquired Ridgeway in November 2012 and literally ran back to Southampton to start counting their money. No joke. The second Verita investigation [V2] clearly documents the leadership failings, and amongst the most appalling is the fact that as soon as the ink dried on the contract, KP and her merry band disappeared.
The Sloven learning disability dream team were to be Dr Kevin O’Shea, clinical director for learning disability, and Amy Hobson, operational director. Yet, they both indicated to Sloven senior leadership team before the acquisition took place that they wished to change jobs and not lead once Ridgeway was acquired – Kevin in September 2012 [V2 12:25] and Amy in Jan/Feb 2012 [V2 12.17]
5b) Leadership response
You’ve guessed it – blame someone else and paint yourself as a victim:
“My learning in hindsight is if you are taking on a new service, and all the knowledge is sat with a couple of people, if those people come out you are then left with a bigger gap… my trauma was that I lost the other person who had the detailed knowledge.” [V2 12.21]
6a) What happened
Katrina Percy was completely wedded to her own version of a ‘business as usual’ model when Ridgeway was acquired in November 2012. She insisted on a plan that saw Day 1 of the merged organisations as some new reality, business as usual, full stop. This was in spite concerns being raised during the due diligence conducted on Ridgeway, despite the two leaders – Kevin and Amy both leaving their posts, despite the CEO herself going off on maternity leave.
Verita concluded that this insistence on business as usual was deeply flawed and meant post-acquisition of Ridgeway was not effective. Let’s be honest, what does Katrina care, she’s got the prime land in Oxford, just have to run the services into the ground.
6b) Leadership response
Sue Harriman, former Chief Operating Officer at Sloven reflected:
One of my overarching reflections was about we came at it in a very, almost, process-driven way, so we almost audited them within an inch of their life, before and after and then, on top of that, we insisted that they do more audits and they have more of an audit culture, and it was like ‘You will do this, you will do that’. There is such a rich source of information about what does and does not happen and were we missing the softer parts, were we missing the bit that actually said, ‘Has anyone really sat down with these guys on day one and said, ‘How do you feel?’ [V2 12:77]
Katrina Percy just reasserted that she was right to do as they did:
“So we ran it as what we call a “T minus 6’. We ran a six-month running process, so we were ready to go live, go live, not start the acquisition process on day one… Effectively, we could go to ‘business as usual’ on day one, and they could run it as part of the learning disability service i.e. as part of the wider Southern Health learning disability services as opposed to a separate division, albeit it is not a very big division in our trust, learning disability services.” [V2 12:70]
7a) What happened
Sloven merged with Ridgeway in November 2012 and in February 2013 a commissioner at Oxfordshire County Council had to write to Katrina Percy, because they’d seen or heard from no-one. That’s three months into their running things, and no-one has been seen since the ink dried on the contract. A complete absence of leadership, slovenly leadership you could call it.
“It felt as if, they won the bid, they got their contracts, they started in November and then they sort of disappeared.” [V2 12:31]
The CCG took a similar view: “Southern Health took over and perhaps didn’t grasp these things that were there quickly enough… I don’t think they knew really what was happening on the ground.” [V2 12:32]
7b) Leadership response
I’m sure you can predict the punch line by now. How did the leadership at Sloven react? Did they reflect and consider they have made a mistake or did they spin, deny and blame someone else? You guessed it…
Katrina Percy, told us that they had been “very held up by the Commissioners” [V2 12:33]
Not just spin, deny and blame, but spin, deny, blame and paint yourself as an expert too, giving ‘learning’ to the regulator:
“My hindsight – and please, this is in hindsight – the learning I give to Monitor to give to other people is don’t wait for the Commissioners. If they accept your tender, that’s the model of care they want. Tell the Commissioners we are now taking it that that’s the model of care you want and we need to immediately move to it in implementation.” [V2 12:33]
On Wednesday 19 March 2013 LB entered the STATT unit. 107 days later he died, an entirely preventable and unnecessary death. The jury at his inquest found the following:
Connor Sparrowhawk died by drowning following an epileptic seizure while in the bath, contributed to by neglect.
Connor’s death was contributed to by very serious failings, both in terms of systems in place to ensure adequate assessment, care and risk management of epilepsy in patients with learning disability at STATT. And in terms of errors and omissions in relation to Connor’s care while at the STATT. [LB’s Inquest Full Jury Findings]
The leadership response was to issue an apology to the media, not LB’s family and to continue to spin and deny the full extent of their neglect. The Mazars report when it was published identified 722 unexpected deaths among learning disabled people or people using mental health services, of the 337 learning disabled people who died unexpectedly only two were investigated as a SIRI (a serious incident requiring investigation).
Less than 1%.
Not fully human.
Slovenly leadership then, slovenly leadership now.
Judgement day. For consistent failings going back to 2011. And so many deaths. Of the 'kind' of people who don't count. #JusticeforLB
— Sara (@sarasiobhan) June 30, 2016