Southern Health NHS Foundation Trust

Luciana Berger Excerpts

Wednesday 8th June 2016 Westminster Hall

[Luciana Berger (Liverpool, Wavertree) (Lab/Co-op)]

It is a great pleasure to serve under your chairmanship this afternoon, Mr Hanson. I congratulate the hon. Member for Fareham (Suella Fernandes) on securing this important debate, and on her heartfelt contribution. She made some excellent points, which I am sure the Minister will be keen to address. It is impossible not to be moved by the catalogue of tragedy that has unfolded at Southern Health foundation trust. This afternoon we have heard the distressing and tragic cases of the most vulnerable people in the country—people with learning disabilities or mental health conditions.

The trust has an enormous responsibility. In my role as shadow Cabinet Minister for mental health I see many trusts across the country, and I am struck by the trust’s size, and the fact that it is responsible for more than 40,000 patients. That is significant in the context of this afternoon’s debate.

We have remembered the lives that have been cut short. We have heard about Connor Sparrowhawk, “Laughing Boy”, who was tragically left to drown in a bath—the same bath in which another patient died in 2006; Angela Smith, who took her own life; David Hinks, who we heard about from the hon. Member for Havant (Mr Mak); and David West, who died in the care of Southern Health. Like too many families, David’s father Richard was repeatedly dismissed when he persistently raised his concerns, and he was treated very badly after the death of his son.

I believe that we are here today only because of the resilience shown by these families, their friends and campaigners. I make special mention of Sara Ryan, Connor Sparrowhawk’s mum, who sadly cannot be with us today but who I am sure will be looking closely at Hansard after this debate. Despite the horrendous way they have been treated after the death of their loved ones, and the barriers—not least financial—that they have faced in their quest for justice, they have never given up in their campaign to reveal the truth.

Only this morning I was at a trade union conference, where I heard from Margaret Aspinall, chair of the Hillsborough Family Support Group. She talked of the struggle that she and the other families of the 96 went through to access justice. I am reminded of the parallels, because she has very publicly challenged why publicly funded organisations can spend significant sums of money on legal fees for inquests, but the families are, in Margaret’s words, left to “beg and borrow”. I have previously asked the Government how much the NHS is spending on legal representations at inquests, to try to shed light on this particularly significant matter. The Minister was not able to give me a reply, but in the context of this debate I urge him to try again. It is particularly relevant and pertinent that we should know how much is being spent while families throughout the country, and particularly in the cases we are speaking about this afternoon, are having to spend enormous sums of money just to access justice on behalf of their loved ones who have passed away.

It should not be left to families alone to have to fight for the answers. Too many people have been denied decent care and systematically let down by the very organisation that was charged with their wellbeing. We have heard about hundreds of unexpected deaths that occurred at Southern Health between April 2011 and March 2015, most of which were not considered to require an investigation. We know that, over the past five years, 10 patients who had been detained for the safety of themselves or others jumped off the roof of a hospital run by the trust. Access to a roof was still permitted to people at risk of suicide.

We have also heard about the reports on Southern Health that have demanded changes and improvements to patient safety—improvements and changes that, by and large, the trust has failed to implement over far too many years. I believe it is a story of chronic management failure. Most astonishingly of all, it is a story of a chief executive who remains in post despite this litany of failures on her watch over a number of years. I cannot imagine a chief executive in any comparable organisation who would still be in post with such a record. I take a different view from the hon. Member for Fareham and the Minister: I do not say this lightly, but I do not believe that Katrina Percy should still be in post. Does the Minister have confidence in the chief executive of Southern Health foundation trust?

Like other Members, I welcome the appointment of Mr Tim Smart as the new chair of the trust, following the previous chair’s resignation. We know that he has recently launched a new appraisal of the capabilities of those involved in the governance of Southern Health, and that is not before time. I understand that he has met some of the victims’ families, and I hope that marks the start of an ongoing and meaningful dialogue, not a one-off encounter. Mr Smart has an incredibly difficult job to do to rebuild faith in the trust and to ensure that governance arrangements are robust and sustainable. Most importantly, he must move swiftly, after months of sclerosis, to ensure that patients are not at risk and that no more preventable deaths can ever be allowed to occur.

When the Secretary of State responded to the urgent question on Southern Health from the Labour shadow Secretary of State last December, he rightly said that, more than anything, people want to know that the NHS learns from such tragedies. But the most recent CQC report shows that Southern Health has not learned from these tragedies. The Secretary of State also said:

“Nor should we pretend that this is a result of the wrong culture at just one NHS trust. There is an urgent need to improve the investigation of, and learning from, the estimated 200 avoidable deaths we have every week across the system.” —[Official Report, 10 December 2015; Vol. 603, c. 1141.]

We know that the case of Southern Health is not unique. In my role as shadow Cabinet Minister for mental health, I receive many pieces of correspondence from people right across the country. I was contacted only recently by Richard Evans, father of Hannah, who took her own life while in the care of the NHS.

Hannah had a very long-standing history of complex mental illness. The conclusion of the inquest was that Hannah had died by hanging. The jury’s narrative verdict listed nine serious failings that contributed to her death, describing her treatment as “limited... inadequate...and insufficient.” The coroner further submitted a regulation 28 report in which he included the full jury narrative, stating that it

“revealed a serious breakdown of care in relation to Hannah”,

an individual with

“exceptionally complex needs who represented a very high risk of suicide.”

One of the most serious failings was that Hannah was able to get hold of an electrical cable, which she later used to take her own life.

Hannah’s tragic case shows that failures of care are not the preserve only of Southern Health; they take place in other parts of the NHS and in other parts of the country. We have also heard of at least three deaths this year of young people in the care of Priory Group hospitals. I am in regular communication with Inquest, a charity that works with those bereaved by a death in custody or detention, which sends me details of case after tragic case from across the country.

The Minister must address these questions in his response. I asked him this in an urgent question last month, and I ask again: does he have full confidence in the governance arrangements at Southern Health? If so, what evidence does he have to support his view? If not, what is he going to do to change, reinforce and strengthen governance arrangements at Southern Health? Is he content with the pace of change at the trust and the degree to which the trust’s board has implemented the recommendations made to it over recent months? What steps has he taken to ensure that similar situations cannot arise in other NHS trusts? What steps will he take to ensure that when a family loses a loved one, they are not left to fight and pay for justice on their own?

On that last point, I hope the Minister can go into some detail, because if any good can come from this sorry and tragic tale, it is that new systems are put in place to ensure that no other families are put through the sorrow and grief that the families of the victims of Southern Health have been put through, and that when deaths occur, they receive full independent investigations. Appallingly, such investigations have happened only on a few occasions.

We all understand that the NHS is a vast, complex institution. It deals with 1 million patients every 36 hours and employs more than 1 million people. Of course human error and tragic mistakes cannot always be prevented, but the lesson of Southern Health is that sometimes things go beyond human error. They can escalate to catastrophic levels of systemic failure, preventable deaths and cover-ups; they can descend into a culture of denial and secrecy; and they can end up at the opposite end of the spectrum of decency and compassion that characterises so much of our national health service and the caring professionals who work for it. That is why we call for a full public inquiry into preventable deaths in the NHS, so that light can be shone, families can grieve, and justice can be done. The victims and their families deserve nothing less.

It should not be left to individual families to have to fight and fund their own efforts to achieve justice. The British public, as the owners and funders of our national health service, need to be reassured that every part of it is working to its highest standards, with the best quality of care, particularly for some of the most vulnerable people in our country.