The 1%


“A failure of leadership at Southern Health. A lack of transparency, missed opportunities, raising the prospect that some deaths could have been avoided if earlier incidents had been properly investigated” 

So said Michael Buchanan in his damming BBC headlining report on Southern Health NHS yesterday. But I can’t be sure at his point if Nico would have been living, safe and well today if “earlier incidents” had been investigated, or in fact if his death was one of those earlier incidents.

Death as “incident”. When you describe it like that you can almost see how easily a culture of non-investigation could thrive in a large NHS Trust.  After all, investigation takes, time, money, resources and a willingness to be thorough and painstaking.  It also requires you to believe that such an investigation is important and necessary.

Of the 12.000 unexpected deaths in Southern Health care, 30% of mental health deaths were investigated but only 1% of the deaths of young disabled adults in their care were even formally investigated.

My son Nico wasn’t even one of the 1%.

Nico was disabled, non-verbal and needed 24 hour care. The fact that he was funny and bright, loving, friendly and kind was irrelevant to Southern Health when he died.  His death was so unimportant to them that they decided that only a “Root Cause Analysis” was necessary.  Not a full investigation.  Just a quick who, what, where and why.  Conducted in house of course, no need to bother outsiders.

But we made a fuss about his death. A stupid time-wasting fuss. How selfish of us.

So Katrina Percy, CEO of Southern Health finally wrote us a letter to shut us up and get rid of us. 6 months after Nico died. 6 months of me making a fuss.  In this letter she told us:

“Although a Root Cause Analysis had been completed, you weren’t informed that this had taken place. You weren’t informed as it was thought this would be distressing for you, but had you been provided with this information, it would have helped you to understand that the Trust was looking to learn from any issues surrounding your son’s death. I am sorry that we did not keep you informed and appreciate that this must have caused you additional distress.”

For those of you who don’t speak “jargon” they’d had an in-house investigation and had decided not to tell us that they’d had one and had also decided not to tell us what had killed my son – because it might upset us.

Southern Health said in their statement to the BBC that “they have been learning from deaths”.   At Nico’s inquest, over 2.5 years after he died rather than show us just how much “learning” they had been doing, Southern Health demonstrated a sharp desire to crush us.  They had spent a considerable amount of public money bringing in a “ringer” a top solicitor well known for his excellent work in winning high profile inquests for public sector organisations.  They lied at the inquest, they mislead the coroner.  They showed us that actually what they had “learnt” was to crush us hard and mercilessly.  Close down our campaign as quickly as they could.  There was absolutely no sense whatsoever that they regretted what had been done.

Now it seems almost inevitable that Katrina Percy will be forced to step down from her job as CEO. Quite rightly.  I cannot comprehend why she didn’t do this herself as soon as she found out that precious young people had died horrible, needless deaths on her watch.  But will she be cast out from Southern Health as the sacrificial lamb?   After her demise as CEO will it just be business as usual for Southern Health and is it possible for us all to stop that from happening?  To what extend should the work of large NHS Trusts be monitored and perhaps more importantly, how can we make sure that they even understand what “doing well” looks like?

Southern Health took over Ridgeway Partnership in Oxfordshire. They took over the running of the house where my son died and every other home, house, hospital and ATU unit that Ridgeway Partnership ran in Oxfordshire.  They changed nothing, staff were re-graded so they could pay them less, but otherwise nothing changed.

Now Southern Health wants to blame poor practices in Ridgeway Partnership for many of these deaths. “It’s not our fault – it was them!”  But the truth is that when you take over another business, if you are good at what you do, you look closely at current practices and where you feel they are weak or dangerous, you make urgent changes.  If Southern Health didn’t like the way that Ridgeway did things, they had ample opportunity to instigate sweeping changes – but they chose not to.  They even kept on the same staff in their same jobs and just gave them snappy new Southern Health style titles.  It was all business as usual.

This suggests to me that they had no real grasp on what excellent practice is and that simply cannot be blamed on the CEO alone. The instigation and continuation of excellent practice can be found at any level.  All it takes is good, well trained managers at all levels, put into place by a board of directors – all of whom know what good looks like and are absolutely determined to deliver it.  Good care costs no more than poor care but what it does require is for the top down of an organisation to want it.

When these huge and damming reports sweep across the media it’s very easy to forget to include the families affected and I’m not even talking now about us or the family of the most high profile victim of Southern Health, Connor Sparrowhawk. I’m talking about the frantic, traumatised families who have their beloved sons and daughters in the care of Southern Health right now.  How do you think they are feeling today?  How do you think they felt when they turned on their TVs last night?

If these families are going to sleep at night they need to absolutely know their children are safe and will stay safe and that means more than just sacking the CEO and maybe a couple of expendable board members. They have already had a bellyful of slogans, jargon and rhetoric from Southern Health – now they want to see good care.  So I suggest that when the dead wood has been pruned from Southern Health, we all do our best to help them become worthy of the people in their care.

But we really shouldn’t kid ourselves – Southern Health are not the only NHS Trust caring for disabled people who have blood on their hands. I strongly suspect that the true figures for unexplained deaths “Death by Indifference” as my friend Beverley Dawkins put it in her 2007 Mencap report, would be so high that you would be staggered.  12.000 unexplained deaths in the hands of Southern Health – how many deaths would that be across the UK if all the NHS Trusts were added together?

In these times of ghastly cuts to our social care system, cuts which frankly put disabled people’s lives at risk – is it possible to instigate reforms, to save lives, deliver excellent care and still come in on budget?

Or are we all just sitting here and waiting to hear the next damming report? The next set of figures?  The next expose of the next CEO?

Exactly this time and this day last year, Nico’s inquest was beginning. I wish with all my heart that I could be sure there will never be another family who will suffer as we do.  But for that to happen we need to look at more than just changing one bad CEO of one Trust.  We need to look at what is happening to the care of our young people nationwide, and urgently.

Nico's Photos_0050


7 thoughts on “The 1%

  1. so sorry for your family and others confronted with the headlining news, very mindful of your thorough preparations including personally investigating the credentials of all involved in Nico’s independent investigation. Clearly you and yours will have used up precious reserves of energy and now this shocking draft. I believe the people responsible for the leak acted in accordance with the true values of their vocation. There is delight and love in every life lived uniquely and it should not be possible for certain unexpected deaths to routinely forgo investigation. Each and every death will be re-visited and the Trust will be responsible for any/every contributing factor found that falls within their duty of care. Truly exhausting and painful for all the families involved with the Trust past and present but unavoidable given the shocking state of affairs reveled to date.

  2. Pingback: Less Than Human. | Who By Fire

  3. Holding all of you in my thoughts and sending all my love. Right now I have no words to express how very wrong this is and on so many levels. Huge hugs. Yvonne xxx

  4. We now know, only 1% of the learning disabled deaths, were investigated, by SLOVEN.

    And, as you say a report last year, stated 3 learning disabled died per day, needlessly, in NHS care, but, these, were only the ones, that were actually investigated.

    So, if all NHS Trusts, are like SLOVEN, that might be 300 per day.

    But, we must also ask ourselves, why SLOVEN has been revealed per se, and why now. i.

    And, why, the many deaths in St Andrews, Northampton, and, other private ‘special hospitals’, and Adult Treatment Units have not, and, probably will not, even, now, be investigated.

    The reason, SLOVEN was exposed, and, political action taken, might be, to further the privatisation, of mental health care, so that more, so called ‘specialist hospitals’, and Adult Treatments Units, like the one Thomas Rawnsley died in this year, are used.

    They are privately run for profit, and, usually owned by the very private corporate venture capital residential care providers, as Thomas’ was, Cambian/Lifeways, so the conflict of interest is greater, and, inadequate care, worse than SLOVEN.

  5. Frightening and it is happening to other families and the arrogance and gagging of people through fear of reprisals is so real and terrifying

  6. Pingback: When deadly care failings are not ‘shocking,’ but predictable… | Dr Mitzi Waltz

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