Statement on behalf of patients and relatives of Southern Health #JusticeforLB
This statement will be given to the press by Richard West after the family meeting with Alistair Burt and Tim Smart has finished. He speaks for all of us in the Justice Shed.
Following the announcements of the future of Southern Health we, the patients, relatives of those that have died and others that have suffered at the hands of Southern Health would like to say the following:
- We are extremely shocked that those who have sat in judgement on this matter would allow Katrina Percy to continue in her role as Chief Executive. We believe it reflects badly on them and their judgement. It is beyond belief given the clear evidence available and a long succession of failures that have come to light.
- We would like to highlight a few of the very important milestones, in this very long, sorry saga of a Hospital Trust dreadfully failing patients, relatives, some staff and others.
- Following on from Mid Staffs and Morecombe Bay it does not seem possible this has happened and is happening.
- For a period of 3 months in 2011/2012, Mike Holder a Health and Safety expert worked for the Trust. He identified that Southern Health Trust that had many problems with the safety of patients and called their attitude to Health and Safety as being dysfunctional. He sent a long letter and associated documents to the Chief Executive Katrina Percy outlining numerous serious failings including the fact that there were ligature risks that had not been addressed by the Trust. He informed the Chief Executive that she was breaking the laws of the land. It is clear that Katrina Percy knew his recommendations but they were not acted upon at the time. Had they been then lives may not have been lost.
- Hannah Groves died in September 2012. She was 18 years of age and she hung herself after failings by Southern Health. A Coroner was very critical of the Trust. They assured him and the public that they had learnt lessons.
- In July 2013, Connor Sparrowhawk was found drowned in a bath in an Assessment and Treatment Unit in Oxford run by Southern Health. He lived with epilepsy, a learning disability and was autism. He was 18 years of age. He had a seizure whilst bathing unsupervised and drowned. The Trust initially tried to say that his death was due to natural causes. His family believed otherwise and started a long, tortuous journey to see justice done. A jury at his Inquest some two years later found that he had died by neglect in a NHS establishment. The whole family have been treated with utter contempt in their quest for justice. It is shameful.
- Following Connor’s preventable death, Dr Sara Ryan (Connor’s mother) had a meeting with Sir David Nicholson the Chief Executive of NHS England who listened and commissioned a report into all deaths at Southern Health since 2011 when they were formed. The shocking and damning report was called “The Mazars Report” and was published in December 2015 to utter disbelief. It showed that only 1% of 374 learning disability deaths had been investigated. Up to 722 people who had died whilst in their care had not had their deaths investigated. The report said there was leadership and governance failings.
- In August 2014, James Younghusband was found hung from a ligature in his bedroom in a secure ward in a Southern Health establishment called Ravenswood. This is one of the ligature points that Mike Holder had tried to warn Katrina Percy was a serious safety issue for patients.
- Between 2011 and 2014 the Trust have spent over £2 million on “Going Viral” a leadership programme and yet have taken over 4 years between 2011 and 2015 to get rid of ligature points in Ravenswood House. In other establishments there still have ligature points that need to be removed.
- Between 2011 and the present time the Trust have commissioned various organisations to review their systems and the way they operate at a massive cost and with minimal impact.
- In the same time this Trust has continually failed CQC inspections. Have failed to take the advice of the CQC inspectors who have told them to take action on lots of matters including on removing ligature points.
- In the same time there have been many deaths of patients where the Trust has apologised at numerous Inquests to say that they had not done the right thing or had not acted correctly. They promised to learn. They did not do so.
- Since the publication of the Mazars report the CQC have returned to Southern Health and found that the governance and leadership had still not addressed including matters from The Mazars report and from the previous CQC inspections.
- NHS Improvement have imposed additional enforcement undertakings on the Trust. It just gets worse and worse.
- The Non Executives are meant to hold the Executives to account. This has not happened before or after Mazars. The Council of Governors are meant to hold the Non Executives to account and they have not been allowed to do this. Katrina Percy has never been questioned at length by the public about her management of the Trust, decisions she has made, the model of care she has imposed since 2011 and to ask her what actions she took after receiving the Holder report.
- We are aware of other deaths of patients of Southern Health where the care and treatment of the patients are likely to be criticised in the near future at Coroner’s Courts. Southern Health have not learnt lessons – the mistakes are continuing.
Sometimes in life it is difficult to understand why certain courses of action are taken or not taken. We cannot understand why this incredulous decision has been made to allow Katrina Percy to remain in her post.
We have not given up and we are not going to go away. Instead we have been energised by this unjust decision to continue our fight for the people that now have no voice.