Category Archives: Southern Health NHS Foundation Trust

When troubleshooting goes bad…

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Blimey. More documents pinging mysteriously into the Justice shed. Including a letter written by the then Sloven board chair to Monitor (now NSH Improvement) raising serious governance concerns in 2011. [Yes. Really]. At first graze, a dense, detailed, informed, harrowing and enraging addition to an apparently unlimited evidence pile highlighting Sloven governance failing.

I’m typing this post listening to Laura Veirs. A vague balm. Rich and I have spent the last three days since the faux announcement of Katrina Percy’s (yet to be properly confirmed) ‘resignation’ in a harsh and agitated space. It’s not about her, as a person. It was never about her as a person. Blimey. She didn’t make it to the Connor Manifesto. But it’s becoming more and more about her. 

Percy failed to lead effectively. We all know that. The board failed, and continues to fail, as an executive board. The Council of Governors remain split between an enlightened minority and the waste of space rest. There remains a consistent and shocking lack of competence, authority, knowledge and sense among both the board and council. Backfilled with a frenzied focus on reputation and apparently unlimited funds to buy in whatever spurious consultancy or legal support they think will magic away the disorder that surrounds them.

Deeply depressingly, the documents leaked to us today were shared with Tim Smart to provide context to his review of the board. Now we don’t know (I don’t think anyone really knows) what Smart based his (30 June) judgement of the board on. We do know he scathingly dismissed the Mazars review during the meeting with My Life My Choice and we now know he must have dismissed the serious concerns raised by the board chair back in 2011.

We also know he agreed to the very recent secondment of Sandra Grant and Flash Gordon to new pastures (as well as gifting Percy a substantially reduced role on a CEO salary). Why you would give a board under serious scrutiny a clean bill of governance health and then start seconding execs five minutes later is a mystery. Oh. Unless you finally, and belatedly, realise the board is as grubby as they come.

Indeedy, it’s probably about time some of the spotlight shifts to Smart and Jim Mackey (the CEO of NHS Improvement My Arse). What this pair of muppets are doing is beyond me. Did they really not anticipate the inevitable backlash against such offensive and scandalous news? Did Smart not realise erasing all whiff of failure in Percy’s leaving statement, blaming press interest, would simply enrage and inflame? What an almighty pigs ear of executive and regulatory ‘action’.

Ironically, one of the biggest failings here is candour and transparency. From where we’re sitting, it appears Smart made the wrong judgement on June 30 because he is incapable of listening. Days later Michael Buchanan broke the news about dodgy contracts. Patient deaths are clearly nothing compared to doshing your mates £millions for going viral nonsense. Once Roy Lilley was on Radio 4 condemning the spiralling of a £300k contract to £5m, the writing was on the wall. Failing governance a go go.

Instead of a clean sweep, an acknowledgement of failings – of letting down hundreds of patients and their families, of a board gone bad – Smart, Mackey (and Hunt?) ballsed it up. Big time. Generating more media attention and public outrage than the publication of the report revealing that Sloven investigated less than 1% of the unexpected deaths of learning disabled people over four years. A report that led to the appointment of Smart as the troubleshooting interim chair.

What a stinking mess. Do the right thing someone. Please.

The Smart and Percy Show

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Rich and I are on leave at the mo. A funny space of walking, a weekend away in Finland (me), going to FrightFest with Will and Owen (Rich), catching up with friends and family and more walking. Yesterday Tom left for a day out at Legoland with Yellow Submarine. Lying in bed, vaguely (not) making day plans (around work stuff) we heard the Sloven CEO’s resignation was imminent. Within 10 minutes there was official announcement.

The day became a media thing. A heightened media thing. Reminiscent of the day of the vindictive cow caller. My phone kept pinging. We were a bit half arsed in our responses and hit or missed Sky News, Huw Edwards, Radio 5 Live, Radio 4 PM, BBC News… ITV Meridian and the Daily Fail just pitched up at home. The cheeky scamps.

It turned out the story was the usual Sloven spin and deceit (with the apparent approval of NHS Improvement). Percy was retaining her salary to do some made up nonsense. Truly extraordinary. Both Percy and Smart blame media attention [I know] for making the chief exec role untenable. The personal media attention levelled at Percy apparently. Mmm.

Not sure anyone was simply gunning for her. Take this piece, for example:

Notwithstanding this point, failing to acknowledge well known and longstanding failures in their statements is deeply offensive. Smart, who has scrambled egg on his face in a big way having endorsed Percy and the board only weeks ago, lists her “successes” in a blatantly fake, arse covering way:

Great resilience, devotion, well suited to lead the trust (and to do vital work with GP leaders), ensured joined up working with health and care organisations, leaving the trust financially sound… and blahdy blah.

Joined up working? Like greedily devouring Oxfordshire learning disability provision, leaving it to rot, allowing people to die [die] and then losing the contract…? How could you write this shite?

Now, we ain’t rocket scientists but both Percy and Smart seem to be talking from a leaving hymn sheet in their statements. Percy signs off:

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While Smart states:

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You don’t wish people all the best at work if you’re staying. Or thank someone for their years of service when they ain’t leaving. So it appears that we will continue to pay Percy’s inflated salary indefinitely while she does, erm, very little. [Chris Gordon in the above piece has already been seconded to NHS Improvement in a you could not make it up move… bizarrely leaving the hapless Medical Director on the board. The person who turned up to LB’s inquest without even doing the most basic homework about the Trust].

What is truly sickening is we all know this is complete bollocks. And it seems there is nothing we can do about it.

The reality is Katrina Percy failed as a leader. And her executive team failed alongside her. As Paul Kemp tweeted earlier, this is what she leaves behind.

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‘Second victims’ and calling a boat a boat

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I’ve lost count of the number of scratchy NHS related tweet exchanges I’ve had with certain human factor fanatics over the past three years. Blooming tedious and always brings in the flying monkey types who don’t engage or discuss but just retweet the too often cultish, Stepford Wifey, non speak.

Sigh.

On a vaguely related note, there has been ongoing discussion over the past two days around ‘no blame’ cultures and accountability. I’ve kind of tried not to get involved but every now and again words like ‘witch hunts’, ‘equal parties’ and the like make me chip in. Earlier today the concept of ‘second victims’ cropped up. Second what…?

Blimey. Turns out there is a body of research around health professionals being ‘second victims’ when a patient is harmed. A concept introduced 16 years ago in the BMJ by AW Wu and apparently uncritically accepted as a ‘thing’. The US based paper shared earlier has the following findings and conclusion around the impact of ‘adverse patient events’:

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Six stages that conveniently sidestep any engagement with responsibility or accountability. What is astonishing – in this paper, I’m sure in the broader ‘second victim’ literature and in the twitter discussions I’ve been involved in or followed as a lurker – is the cosy, untouchable, (sadly too often smug) portrayal of healthcare professionals’ working practice being beyond scrutiny. No accountability (or heaven forbid, criminal prosecutions), here thank you. Move along now. We’re doing our holier than thou, extra special work. If anything goes wrong, we need help to start to enjoy our work again.

And zip all reflection about those  left brutalised by the death of their child, parent, grandparent, family member or friend…

The fakery and indulgence around this second victim nonsense is laid bare in the conclusion of the article where the authors state:

Regardless of sex, professional background or years of experience, all participants in our study easily recalled the immediate and ongoing impact of their specific career jolting event.

A career jolting event is nothing like experiencing the preventable death of a loved one. Please don’t ever pretend it is.

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Tama on vene [translation from Finnish: this is the boat].

Postscript: I’m not ignoring or denying that healthcare staff may/must be devastated by the death or serious harm of a patient here. It simply ain’t comparable to the experiences of families.

The GMC investigation (Part 2)

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Memorial bench lichen at Wolvercote Cemetery. August 2016

Delved back in time to trace the steps of this investigation and it’s worse than I remember. Part 1 covered how, after sending a lengthy and detailed letter of referral, I had to return the consent form to the GMC within 8 days or risk delaying the investigation. Back in June 2014.

So how have the intervening 26 months been filled? 26 months…? Good question.

We started with six weekly updates by letter (good) which tailed off towards the end of year 1.

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Blimey. Another tight deadline for us. Waiting on Sloven as ever. 10 months to get an expert report, get the referred doc to respond and, er, think about what to do next. But at least it looks like the investigation is pretty much finished.

In May 2015 I replied to an email from a journalist saying among other stuff the “GMC should really be any day now (they started last June) and it was at the final decision stage the last I heard, a few weeks ago”.

I look back on these exchanges now and wonder at the utter naivety they reveal on our part. And the (at best) indulgence demonstrated by the – no urgency here, fuck off and wait for as long as it takes, you bereaved families, you – General Medical Council.

The next communication was a letter from a GMC in-house legal person, sent by email on July 15 2015, with this vaguely hilarious subject heading:

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Please respond. That’s all we do. Like obedient (through regular beatings) puppies. Grateful for any crumb of progress. Though this particular crumb was a surprise. Fifteen months after our initial referral:

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What the actual fuck? Why/how does the need for ‘confidentiality’ erase the need for effective and sensitive communication? Is there a collective historical amnesia in operation within these regulatory bodies that means everything that came before is just tossed out with the rubbish? Did no one involved really not pipe up and say something like:

Er, this is a teensy bit awkward given the referral was made over a year ago now. And we’ve led this family to believe that the investigation is pretty much finished. We really should contact them to explain exactly why we are only now collecting statements*.

Nope.

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To be continued.

*We still don’t know.

 

The GMC investigation (Part 1)

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Starting a series of posts about our experience of a GMC investigation. I don’t suppose it will be a big surprise to hear that this is utterly shite. I don’t  know what to call it. Journey? Process? Piss take? Shambles? I dunno. You decide. I’ve kind of held off from unpacking this [fill in from above] in case it somehow influences or ‘biases’ the outcome of the ‘investigation’ but have reached a point at which I sadly realise that there is no outcome to muddy, bias or de-rail. Just an inept, unwieldy, careless, brutal, inhumane (no)thing. 

Back to 2014. When I first referred Dr X after Sloven repeatedly refused to let us know anything about possible staff disciplinary procedures. We got wind that Dr X had relinquished her licence and gone to practice outside the UK.

The referral was harrowing. Having to lay out the reasons why we thought Dr X failed LB (it wasn’t (and isn’t) our job to do so) was deeply painful. Luckily our fab solicitor helped us.

A month later we receive an acknowledgement from our newly appointed GMC investigation officer. Kicking off with a breezy opening:

Thank you for your letter of 22 May 2014 about Dr X.

I will be investigating your complaint and will be your main point of investigation during the investigation.

Note to GMC. We really ain’t complaining about the actions of Dr X. Our son died. Something you seem to erase from this exchange. LB isn’t mentioned until the fifth paragraph. Halfway through the letter:

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This is the grist of the letter. The consent form. Five out of the 10 paragraphs focus on the urgency of returning the consent form. No acknowledgement that someone died. There is no empathy, understanding that we may be in a pretty crap space. The only vague mention of this is towards the end of the letter (before a final demand for the consent letter):

Some people find making a complaint to us a stressful experience… [link to Victim Support]

The irony in this sentence speaks for itself. I think I’ll leave Part 1 here. I returned that consent form before the 27 June 2014 deadline. The only deadline met in this brutal process.

The GMC (are they actually medics?) gave us 8 days. We’re now at 2 years and 3 months with no idea of the end date. Yet another classy bunch.

PS. Hoping I don’t need to spell out the ‘learning’ here but will in a summary post at the end.

Puff the Mackey Dragon…

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It sounds like there’s a dose of musical chairs going on with the Sloven executive. Sigh. Word in the shed is that Sandra Grant, who does summat and goes back to the olden days with Katrina Percy, is off for a six month secondment while Chris Gordon, Chief Operating Officer  (COO) and Director of Patient Safety, is apparently heading to NHS Improvement for 12 months as an improvement director. [I know…]

He, Lesley Stevens and Katrina Percy, are holders of the obscene salary and pension pots exposed a few weeks ago.

In the NHS (unlike much of the commercial sector) it appears when you fail at exec level you simply get moved around in a never ending chess like game. Only one in which the board is so worn the squares are no longer visible and the grubby pieces have been handled so often they’re unrecognisable. And there are no ‘rules’. Just fakery and nonsense played by overly paid, under qualified (in real terms) bods who share a common language, code and cloak of protective armour invisible to the rest of us (who pay their over inflated salaries).

I can remember Tim Smart, the newly, NHS Improvement, appointed interim Sloven chair (the Flash of yesteryear) at the My Life My Choice meeting. Tapping his nose and saying with much gravitas:

Just remember Sharon Shoesmith…

Effectively stopping any discussion about anything.

So, two or three months on from the “action” taken by NHS Improvement in response to repeated evidence of Sloven board failings, where are we exactly? And what did “Remember Sharon Shoesmith…” mean?

Well. Crap all to the Shoesmith question. That was probably part of Smart’s briefing from NHS Improvement… “Just mention Shoesmith when anyone asks a dodgy Q“.

The board got the all clear from (the previously failing) Smart on the basis of fuck knows what. The consistently underwhelming (at best) CEO was removed of operational duties and told to focus on strategy. The COO has gone to NHS Improvement and will only work 2 days a month on Sloven operations. And Grant who, after a quick google, is Director of People and Communications, is off for six months. Blimey. Who is keeping this leaky boat afloat in the land of Solent Lee?

Meanwhile, in addition to the salary/pension scandal, financial irregularities are blasted across the news. Failing, upon failing.

NHS Improvement… I can’t help thinking the question Shaun Picken from My Life My Choice put to Katrina Percy at the January board meeting is relevant here:

Katrina, why didn’t you ask for help? You clearly need it.

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Of mice and (NHS) monstrousness

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A story ‘broke’ yesterday about extortionate NHS interim director costs. Sickening figures of waste, greed and mismanagement. At senior levels. Again.

In another of those ‘you couldn’t make it up’ NHS moments, the highest paid interim Improvement Director named in the report, Steve Leivers, was helicoptered into the trust Tim Smart, now Sloven interim Board Chair, previously ran. Yes. Really. Not Smart in non action. Again.

I read this latest news having been unable to move beyond Chris Hatton’s recent analysis of Sloven’s annual report. Cut and paste Katrina. And extraordinary senior exec salary figures. With Lesley Stevens, Medical Director at the top of the ‘leader’ board. A cool £365-70k per annum including jaw dropping pension contributions. How can she possibly ‘earn’ this sort of dosh? Let’s have a look at her performance during LB’s inquest last October.

Lesley Stevens and LB’s inquest

Reasonably confident while reading out her evidence and then being (sleep) walked through clearly rehearsed questions by the Sloven barrister, she floundered big time when questioned by the six remaining barristers. Her answers so deeply insubstantial (a generous interpretation) it was as if the courtroom had switched to watching CBeebies.

£365-70k per annum…

Some examples:

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LB died in July 2013. The (post Mazars review) CQC inspection in January 2016 found the Sloven epilepsy policy had yet to be signed off. Paul Bowen, QC, carefully questioned each Sloven staff member about their knowledge of epilepsy during LB’s inquest. No one answered in other than the vaguest ‘ain’t got a clue’ terms. There was no up-skilling staff over two years after LB’s death.

[Howl].

LS3Here Paul Bowen seeks clarification of Stevens outlandish statement that all learning disabled patients with epilepsy were reviewed before the CQC inspection in September 2013. At that point, Sloven were still spinning the line that LB died of natural causes. They did nothing to check the provision in STATT (it failed on all 10 domains inspected 6-8 weeks after he died) let alone review patients with epilepsy in their wider provision/outposts.

A blatant and contemptible lie. Perjury to us herbs outside of senior NHS circles.

LS2Paul Bowen tries to drawn Stevens on the failure of the RiO system. A failure that persists to this day. She resorts to her default response. A murmur/mutter noise reminiscent of the dog ate my homework type responses from school. Not the sharp, authoritative, informed, engaged response you’d expect from a senior exec at an inquest over two years in preparation, with nearly £300k squandered on ‘defence’ costs.

When questioned by Adam Samuels, another barrister, about the reduction in Band 6 and 7 staffing reductions in STATT (and the next door John Sharich House), Stevens says:

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‘We make savings where we have to make them…’ On frontline staff. While you continue to draw an obscene salary

Monstrous. And remorseless. Just one, among so many.

When did the NHS we grew up with, took for granted and loved, become so riddled with greed and rot… with complacency and arrogance, with inaction and protection. At senior levels?

Cut and paste leadership and the pro-Percy HQ

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Sloven financial irregularities (that is, bunging apparently endless amounts of public dosh to mates for little or no return) hit the news on Friday, via Michael Buchanan. Today Chris Hatton published his analysis of the Sloven (or Sudden Wealth) 2015/16 Annual Report. I can’t recommend reading this post enough. Just one titbit (and there are so many) is that KP simply cut and pasted the last paragraph of her closing statement from the previous Annual Report. Unbelievable action in any annual report, but breathtaking given the content and context. The end of the paragraph states:

Notwithstanding this, my review confirms that the Trust is taking appropriate actions to deliver the agreed undertakings and ensure compliance with the Trust’s provider licence and to address any weaknesses in the system of internal control.

Those failings and enforcement notices clearly just roll over yearly. Sickening demonstration of the contempt the Sloven board have for patients, staff, regulators and the wider NHS, and the public. And further indication the Sloves (or Suddens) are not capable of improvement.

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What is actually going on here?

Let’s have a little look see at what’s happened since the Mazars review was published:

  • In December 2015 Jeremy Hunt announced the CQC would go in and inspect Sloven again with a focus on death reporting.
  • In April, the CQC announced serious (continuing) failings.
  • Ball over to NHS Improvement who send in Clive Bell as Improvement Director and, subsequently, Tim Smart as Interim Board Chair.
  • Tim Smart did a tinpot investigation (no family involvement), Katrina Percy was subjected to six hours of psychometric tests and he gave the board a clean bill of health. A week ago he commended the performance of the board to the Council of Governors (audio from 17.10 here…)

 

So blinking awkward. In the light of the Buch-Hatt findings this is a serious egg on the face situation for Smart (who signed off the Annual Report) and Jim Mackey (CEO of NHS Improvement). It also offers some chunky old clues about where pro-Percy HQ is based. [And believe me, many people are asking this question…] Jezza took action, the CQC took action, things get snarled up in an NHS Improvement pretend party. Interestingly, a Sloven staff fairy heard that Sloven exec, Paul Streat (who worked at, er, NHS Improvement before joining the trust) was arrogant and dismissive about #JusticeforLB in a Senior Viral training day.

Mmm…

We heard yesterday a rumour that KP won’t be returning from her holiday after pressure from the Department of Health. Jezza now has Alistair Burt’s (love him) portfolio for mental health/learning disability issues. He has the ball firmly back in his court. Here’s hoping he takes action (or further action if Percy has been pushed) and removes other culpable board members. The rot in that room is extensive.

He should then perhaps ask questions of Mackey and his merry band. It really ain’t the job of campaigners and journalists to reveal what is in full sight of NHS Improvement, NHS England and the Department of Health.

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Woman on all fours

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In honour of the £5.365m of our money spent on this shite. Here is the woman on all fours. Who called it for what it was.

 

Update: September 25 2016

A day or so after posting this in July, our solicitor got in touch to say a Sloven solicitor had been in touch:

She said that there is a video which has been posted on your blog which contains a female member of staff […]. Apparently that member of staff withdrew consent in relation to that video some time ago and so the Trust has not been using it and she has reported that the republishing of the video is causing her a lot of upset and therefore wondered if it could be taken down.

At the time we took it down immediately.

Today, we found out that the current total paid to Talentworks (who are behind the Going Viral programme talked about in the short film) is now £5,861,424.03. Another £500k since Michael Buchanan’s original expose?

I’m reposting the film. I’m sorry to the staff member if this causes upset (and please contact me directly if it does – posting a comment below for the first time is private) but the full extent of the rubbishness of the training needs to be seen.

Going viral. At nearly £6m of NHS money.  Talentworks? Gone to ground…

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When trusts go bad

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Walked into Oxford earlier with Rich. One of those days when there were no end of brilliant photos to take. Including a cheeky bee.

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Got home to find out one of the rebel governors, Peter Bell is under formal investigation by Sloven. Yep. Sloven are formally investigating the actions of a (rare) governor.

Sloven who:

  • initially said LB died of natural causes and all due process was followed.
  • tried to stop the publication of the first Verita investigation which found LB’s death was preventable.
  • spent nearly £300,000 on legal expenses at LB’s inquest to try to avoid accountability.
  • spent nearly £50,000 to try to sink the Mazars review into their death reporting.
  • have been found to be failing by numerous coroners over the past five years
  • etc, etc, etc…

Blimey. A formal investigation…
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‘Seriously derogatory remarks’…. Not sure where, in the guvs’ code of practice, it states ‘thou shalt not say owt negative against the hallowed trust’. What a load of bullying bullshite. Those of you following this deeply harrowing tale of a trust gone bad will know that an extraordinary meeting to discuss a vote of no confidence in the Sloven leadership was stopped on May 17 by interim chair, Tim Smart. He got the Capstick heavies involved. The discussion remains to be had. Now this.

Truly, truly extraordinary.

Extraordinary timescales too. An ‘investigation’ into the actions of a governor with such priority it can be sorted in a month. We’re into the fourth year of investigations into LB’s death. GMC, NMC, HSE.. Every one of them drawn out because of Sloven slovenliness. Delay and obfuscation.

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LB died. He died. Without any accountability. But the investigation into the actions of a governor is racing on. Interviews, evidence collecting and all. By an organisation who failed to investigate 100s of unexpected deaths in their care. I almost think I’ll wake up in a mo. Surely this can’t be happening in full view of NHS Improvement, NHS England, the CQC and Jeremy Hunt?

Surely…

In a final piece of [no words left] the Sloven annual report has been signed off.

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My incredulity monitor has finally broken.