Dear Chief Executive of Southern Health,
In response to the CQC report into the two units at Slade House, Oxford you issued a statement yesterday, reported here. You are quoted as saying “we were most concerned to learn of the issues brought to light by the CQC‘. The press release on the Trust website states; We are concerned the points raised in the report did not come to light sooner and have launched our own internal investigation.
I’m a bit confused about this. You seem to be suggesting that someone should have pointed out these failures to you earlier? I suppose a robust and effective internal quality assurance process would have alerted you to these failings but we now know this was one of the failing areas in the unit. There were other, weighty, indications though.
Our son died unexpectedly in the unit. Around ten weeks before the inspection. A big flag, I would have thought, that some scrutiny was needed urgently. According to the Trust Board minutes (23.7.13) early investigations into LB’s death suggested that appropriate systems and processes were in place. That’s pretty puzzling. How did these early investigations fail to identify at least some of the concerns that leapt out at the inspection team only weeks later?
And then, again in July, only two days after the Trust Board meeting, the Clinical Commissioning Group (CCG) minuted ongoing concerns about the safety culture and quality of patient care in the unit. Apparently these concerns had been allowed to drag on since 2011 but the CCG were working with you to resolve them. Another fairly ‘in your face’ indication that there were issues in the unit.
I’m sure (hope) you understand that the findings of this inspection are harrowing for us. Our son drowned in the bath in an NHS setting which has been judged so poor it’s now effectively closed. It’s safer for patients not to be admitted.
So it would have been more appropriate if you hadn’t ended your statement; “We are pleased to see our actions and plans are already changing the services provided at Slade House and we look forward to welcoming the CQC back for a further inspection in the coming months.” Pretty uncomfortable reading. A bit of humanity, thought and respect would have perhaps steered you from writing this as if you’re inviting a new mate back for a cup of tea. It’s not really that sort of gig.
LB was a much loved, adored and horribly missed son, brother, grandson, nephew and friend. He died. In a unit run by your organisation in which serious failures in care were identified.
And one last thing. You mention in your statement that staff are being supported through the review process. We hope that the patients were supported through the experience of LB dying on the unit (as well as the changes they’re now experiencing). It must have been an enormously traumatic experience for them.
According to the Press Release, it appears that Katrina Percy was only formally responsible for the unit since… yesterday.
‘Katrina Percy will resume her role as Chief Executive following a period Maternity leave. (sic)
Katrina takes on formal accountability from 27 November 2013.’
So whose watch *was* it that things got so bad on? Murkier and murkier…
That would be someone called Sue Harriman. See http://www.southernhealth.nhs.uk/about/who/board/executive-directors/.
Lesley Munro clinical director learning disability
Brilliant letter Sara!
‘Concerned to learn’ , ‘brought to light’ , ‘come to light’ …… I get so angry! Good leadership means having good knowledge of what is happening on the shop floor at all times, not waiting for a team of inspectors to come along, but they speak as if they were totally unaware of day to day life in the unit. Professionals caring for children / young people / adults with a learning disability are ‘in loco parentis’ and have a responsibility to ensure the emotional and physical security of those entrusted to their care. I will never understand why not even one member of staff felt the need to whistle-blow. With over 25 years experience in Special Needs I cannot comprehend anyone working day in day out in a LD environment and not holding the children’s / adults’ needs close to their heart and striving to provide them with the very best of care.
Oops sorry, I’ll get down off my soapbox!
Stay strong, love Jenny xx
“The staff are being supported through the review process” … What about support for the family who so tragically and inexcusably lost their son…words fail me!
This is what leapt out of the report for me as well.