Southern Health NHS Foundation Trust

Suella Braverman Excerpts

Wednesday 8th June 2016 Westminster Hall

[Suella Fernandes (Fareham) (Con)]

I beg to move,

That this House has considered governance of Southern Health NHS Foundation Trust.

It is a pleasure to serve under your chairmanship, Mr Hanson. I am grateful for the opportunity to open this important debate on the governance of Southern Health NHS Foundation Trust, a subject that has been the cause of mounting public concern over recent months. It has risen up the agenda as more information has come to light. It is right that we, as Members of Parliament, now have the chance to address it and to air our constituents’ concerns. For some, that is not a concern of just a few months’ standing, but a story that goes back many years.

For a number of patients under the care of Southern Health and, particularly, for the families and friends of those who have sadly died, this has been a long-running and painful saga. We will not resolve it for them today but we can ensure that the issues they care about are properly aired in public and are brought to wider attention. I pay tribute to those relatives and campaigners, some of whom have come to Westminster today. I was glad to be able to meet with them earlier and to hear from them in person before the debate. I also thank the Minister for sparing the time to join us and to hear their experiences. With the permission of the relatives, I will refer to some of their stories during my remarks and other colleagues may also want to do so, where appropriate.

As well as having a connection to the subject as a constituency MP, I have taken an interest in the wider issues through my role on the all-party parliamentary group on Hampshire and Isle of Wight, on which I lead on health issues. The area covered by Southern Health goes wider than Hampshire, of course, and we have invited colleagues from elsewhere to our meetings when the subject has been under discussion.

Since last autumn, we have had a series of meetings with representatives of Southern Health, most notably with Katrina Percy, its chief executive, and other senior directors. Those meetings have allowed us to put robust questions to them and to hear their side of the story. Although I cannot claim to have been wholly satisfied by the answers we have received, I thank Ms Percy and her team for engaging with us on our concerns. Just yesterday, we had a very useful meeting with the new interim chairman of the trust, Tim Smart, and I extend our thanks to him.

[Mrs Maria Miller (Basingstoke) (Con)]

On behalf of many other MPs from Hampshire, I commend my hon. Friend on securing this debate and on the tenacity with which she has led on the issue on our behalf. She mentioned the appointment of a new chair. Does she feel that, under the new leadership, we will see more assurance from the Care Quality Commission that Southern Health has actually understood what changes are needed for the future? Some CQC reports we have read suggest that the problems that have been raised have not been addressed in a swift manner. Does my hon. Friend share my concern or does she think we will see progress?

--- Later in debate ---

[Suella Fernandes]

I am grateful for my right hon. Friend’s point and I thank her for her work and for standing up for her constituents who have been affected by the issue. We have met with members of the CQC and with NHS Improvement, and we put those points to them directly. I share her concern, particularly on behalf of families and relatives, who would like swifter action in future. However, I am grateful to those organisations for keeping us informed and for taking the time to ensure that MPs are briefed of their actions and plans.

The facts of the issue are well known to many of those here today and to those watching beyond Westminster. However, in opening the debate, it is important for me to recount the broad sequence of events and key facts to help those who may not be familiar with them and because they deserve to be put on the record as the backdrop to the rest of the debate. Let us begin at the beginning.

The tragic starting point of the story was the death of Connor Sparrowhawk. Connor, who had autism, a learning disability and epilepsy, was 18 when he was admitted to Slade House in Oxford in March 2013. The facility was a learning disability short-term assessment and treatment unit run by Southern Health, which had taken it over from the previous provider, Ridgeway, in November the previous year.

On 4 July 2013, Connor was found submerged and unconscious in a bath at the centre. Staff tried to resuscitate him and an ambulance took him to John Radcliffe hospital but, sadly, he died the same day. The initial post mortem examination concluded that Connor drowned as the result of an epileptic seizure. Southern Health carried out a serious incident requiring investigation report and an initial management assessment, and commissioned an independent consultancy to undertake an internal investigation. That investigation concluded that Connor’s death was preventable and stated:

“The failure of staff at the unit to respond to and appropriately profile and risk assess CS’ epilepsy led to a series of poor decisions around his care…The level of observations in place at bath time was unsafe and failed to safeguard CS.”

Following the publication of that first investigation report in February 2014, Oxfordshire Safeguarding Adults Board and NHS England had ongoing concerns about the quality and safety of learning disability services provided by Southern Health in Oxfordshire, and the improvements that needed to be made. They therefore commissioned a further report in June 2014, which was charged with looking at whether the way in which learning disability services were commissioned or managed contributed to Connor’s preventable death.

The new report was published in October last year and contained a number of criticisms. It stated that there had been warnings about the standard of care in facilities including Slade House, and criticised the management processes following the transfer of services to Southern Health. It found that

“for Southern Health to only rely on its normal reporting mechanisms without addressing the…warning and ensuring that information from local managers was accurate was a serious failure.”

It also found that

“the trust did not evaluate or address the known concerns about the quality of local leadership”,

and that:

“An over reliance on a ‘business as usual’ approach to this acquisition was not appropriate.”

The report concluded:

“Southern Health should have ensured that any deterioration in the quality of services could be identified quickly and by processes that Southern Health had confidence in.”

That was the first serious criticism of the overall management of the services.

[John Howell (Henley) (Con)]

My hon. Friend described a catalogue of disasters. From the conversations she has had, what confidence does she have that the situation has been put right? I represent an Oxfordshire constituency. Can we have confidence in doing business with Southern Health?

[Suella Fernandes]

From speaking to families, relatives and patients, it is clear that they are struggling to have confidence in the services provided by Southern Health. The very reason that the debate it happening is so that we can air those concerns and, hopefully, find a pathway to restoring public trust. That is clearly the challenge facing the organisation.

[Mims Davies (Eastleigh) (Con)]

I thank my hon. Friend for securing this important debate. I also thank the Minister for the help that he is giving us across Hampshire and in the Southern Health area, and for taking the issue seriously.

Families feel concerned about their vulnerable loved ones. Despite changes in care plans and promises when things have gone wrong, families are not seeing changes. In fact, they feel that, in very vulnerable situations, it is sometimes better to be at home than in the so-called care of Southern Health. That has come up in constituency surgeries. I, like other hon. Members, feel that this debate and other investigations into Southern Health should get to the bottom of that.

[Suella Fernandes]

I thank my hon. Friend for highlighting the problems communicated to her by families, which echo and reflect the precise concerns about which the families sitting in the Public Gallery feel strongly. They emphasise that this is not an isolated issue. This is something that we all need to take seriously.

The Mazars report is the next chapter in this story. At the request of Connor’s family, NHS England commissioned an independent report into the deaths of people with learning disabilities or mental health problems while under Southern Health’s care. The report reviewed the deaths of people in receipt of care from mental health and learning disability services in the trust between April 2011 and March 2015. The report sought to establish the extent of unexpected deaths in those services and to identify issues that needed further investigation.

The report was published in December 2015, and its main findings included, first, that many investigations into deaths were of “poor quality” and took too long to complete. Secondly:

“There was a lack of leadership, focus and sufficient time spent in the Trust on carefully reporting and investigating…deaths”.

Thirdly, there was a lack of family involvement in investigations after a death and, fourthly, opportunities for the trust to learn and improve were missed.

Of the 1,454 deaths recorded at the trust during the period under investigation, 722 were categorised by the trust as unexpected. Of those, the review looked at 540 and found that only 272 unexpected deaths received a significant investigation. The report did not specify how many investigations there should have been, but it drew attention to the limited number of deaths that were investigated in different categories. The trust has questioned the use of some of those figures, but the picture painted overall was one of inconsistent standards for investigations, raising the worrying prospect that an unspecified number of deaths may not have been investigated properly. The question of whether there may have been other preventable deaths like that of Connor Sparrowhawk could not be definitively answered, which has led to a great deal of concern among the trust’s patients and something of a breakdown in confidence. Understandably, people want to know that they or their loved ones will be safe in the care of Southern Health. Those whose relatives have died while under the trust’s care need reassurance that the investigations were properly conducted and that the deaths were not also the result of avoidable errors.

My constituent Richard West is one of those relatives. His son, David, died in 2013, and he has been seeking answers from the trust ever since. At times, the handling of his case has been very poor indeed. Mr West, a former detective and policeman, says that he was ignored and was even told by a representative of the trust that the deaths of patients in its care were “like an airline losing baggage.” I know from speaking to other families that others have experienced similarly insensitive treatment.

The Mazars report contained serious and specific criticisms of the trust and its management. In particular, it levelled criticism at the board itself for the failures. It found that

“there has been a lack of leadership, focus and sufficient time spent on reporting and investigating unexpected deaths of Mental Health and Learning Disability service users at all levels of the Trust including at the Trust Board.”

[Mr Andrew Smith (Oxford East) (Lab)]

I applaud the hon. Lady on securing this debate and on her excellent speech. In just about any other organisation, such a searing indictment of the board and, by implication, its executives would have resulted in their resigning. Is she surprised that they did not simply stand down and accept responsibility, as they should have?

[Suella Fernandes]

There is a lot of pressure from the public, patients and families for people to step down, and the resignation of the chairman of the board is a reflection of the seriousness with which Southern Health takes this issue.

The report continued:

“Due to a lack of strategic focus relating to mortality and to the relatively small numbers of deaths in comparison with total reported safety incidents this has resulted in deaths having little prominence at Board level… There are a number of facets to this poor leadership…: a failure to consistently improve the quality of investigations and of the subsequent reports; a lack of Board challenge to the systems and processes around the investigation of deaths…; a lack of a consistent corporate focus on death reflected in Board reports which are inconsistent over time and which centre only on a small part of the available data; an ad hoc and inadequate approach to involving families and carers in investigations; a lack of focus on deaths amongst the health and social care services caring for people with a Learning Disability; limited information presented at Board and sub-committee level relating to deaths in these groups…; and a lack of attention to key performance indicators…indicating considerable delays in completing…investigations.”

The report also found:

“There was no effective systematic management and oversight in reporting deaths and the investigations that follow… The Trust could not demonstrate a comprehensive, systematic approach to learning from deaths”.

In what I consider one of its most damning findings, the Mazars report also found evidence of repeated warnings being ignored:

“Despite the Board being informed on a number of occasions, including in representation from Coroners, that the quality of the…reporting…and standard of investigation was inadequate no effective action was taken to improve investigations”.

The report also stated:

“Despite the Trust having comprehensive data relating to deaths of its service users it has failed to use it effectively to understand mortality and issues relating to deaths of its Mental Health or Learning Disability service users.”

By any measure, those criticisms were immensely serious and required a robust response.

Following the report’s publication, my right hon. Friend the Secretary of State for Health expressed his determination to learn the lessons of the report and set out a number of measures to address the issues raised, including a focused inspection by the Care Quality Commission looking in particular at the trust’s approach to the investigation of deaths. As part of that inspection, the CQC was asked to assess the trust’s progress on implementing the action plan required by NHS Improvement and on making the improvements required by its last inspection, published in February 2015. Separately, the CQC was also asked to undertake a wider review of the investigation of deaths in a sample of all types of NHS trusts in different parts of the country. That is particularly important because we need to know whether the problems and failings at Southern Health are exceptional outliers or whether there is a similar problem in other parts of the country.

The trust accepted the findings of the Mazars report and apologised unreservedly for the failings identified. NHS Improvement set out in January 2016 its plans to provide assistance to the trust to ensure that it delivers on plans to implement the agreed improvements, which include the appointment of a new improvement director and the taking of advice from independent experts. All those measures were agreed by the trust’s management, and in January we had a letter from the chief executive officer setting that out.

[Kit Malthouse (North West Hampshire) (Con)]

I congratulate my hon. Friend on securing this important debate. She is outlining that there is an improvement plan, that the board has agreed and that NHS Improvement is helping, but one thing that seems to be frustrating people, particularly in my constituency, is the lack of a hard date on which we can judge that the corner has been turned. Does she agree that it would be sensible for NHS Improvement, or the board itself, to set some kind of deadline by which a judgment can be made? Otherwise, improvement is purely on the never-never and we will never know publicly whether the trust has got to where it needs to be.

[Suella Fernandes]

My hon. Friend makes a sensible suggestion, which I echo. A deadline with key targets and dates would be hugely valuable, not only in motivating people and focusing minds but in restoring public trust in all the organisations involved.

[Dr Daniel Poulter (Central Suffolk and North Ipswich) (Con)]

I congratulate my hon. Friend on securing this debate, and on her articulate explanation of the issues involved and the tragedies that have befallen a number of patients.

Clearly there has been a failing of clinical governance in the trust on a massive scale. However, I wonder whether my hon. Friend will reflect on two points. First, it is very difficult to deliver improvements in quality in a resource-poor environment, notwithstanding the clinical governance issues, and we know that child and adolescent mental health services and learning disability services have been chronically underfunded for many years nationally.

Secondly, people with learning disabilities often have complex physical healthcare needs as well as mental healthcare needs, and improved staff training needs to be put in place nationally. That needs to be properly resourced and funded if we are to make a meaningful difference and get things right for people in the future.

[Suella Fernandes]

I totally agree with my hon. Friend’s observation. There is a challenge here. This is unfamiliar territory for the NHS, and funding will be necessary to support any new attempt to make progress following debates such as this one.

Inspectors from the Care Quality Commission visited Southern Health as part of the planned inspection during January of this year. Following that inspection, the CQC announced on 6 April that it had issued a warning notice to Southern Health, telling the trust that it must make significant improvements to protect patients at risk of harm while in the care of its mental health and learning disability services. The announcement stated that the notice required the trust to improve its governance arrangements to ensure that there was robust investigation and learning from incidents and deaths, to reduce further risks to patients.

The team of inspectors also checked on improvements that had been required in some of the trust’s mental health and learning disability services following previous inspections. They found that the trust had failed to mitigate significant risks posed by some of the physical environments from which it delivered mental health and learning disability services.

On the wider issue of reporting deaths, the inspectors found that the trust did not operate effective governance arrangements to ensure robust investigation of incidents, including deaths; did not adequately ensure that it learned from incidents, so as to reduce future risk to patients; and did not effectively respond to concerns about safety that had been raised by patients, their carers and staff, or to concerns raised by trust staff about their ability to carry out their roles effectively.

All those findings, and the serious step of issuing a warning notice, reinforce the most serious of the Mazars findings. Dr Paul Lelliott, the CQC’s deputy chief inspector of hospitals and lead for mental health, was quoted as saying that the services provided by Southern Health required “significant improvement”. He said:

“We found longstanding risks to patients, arising from the physical environment, that had not been dealt with effectively. The Trust’s internal governance arrangements to learn from serious incidents or investigations were not good enough, meaning that opportunities to minimise further risks to patients were lost.

It is only now, following our latest inspection and in response to the warning notice, that the Trust has taken action and has identified further action that it will take to improve safety at Kingsley ward, Melbury Lodge in Hampshire and Evenlode in Oxfordshire. The Trust must also continue to make improvements to its governance arrangements for reporting, monitoring, investigating and learning from incidents and deaths. CQC will be monitoring this Trust very closely and will return to check on improvements and progress in the near future.”

The CQC published the full report of its January 2016 inspection at the end of April 2016. It confirmed the concerns that had been raised in the warning notice and gave further details of specific issues. The chairman of Southern Health’s board, Mike Petter, resigned the day before the report was published.

On the same day that the CQC published its warning notice, NHS Improvement issued a statement announcing that it was seeking further powers to intervene in the trust’s governance, to ensure that the trust complies with the improvements required of it. NHS Improvement said that it intended to insert an additional condition into the trust’s licence to supply NHS services, which would allow NHS Improvement to make management changes at the trust if progress was not made on addressing the concerns that had been raised.

The additional condition was imposed on 14 April, and the statutory notice contained severe criticism of the trust and its leadership. It stated that undertakings that the trust gave in April 2014 that it would comply with enforcement notices relating to breaches of its governance conditions were yet to be delivered in full. It notes that additional undertakings were made by the trust in January 2016 in response to the Mazars report and summarises the CQC’s findings from its inspection in January, saying that the warning notice had identified “longstanding risks to patients” that had not been addressed. It then said:

“In the light of these matters, and the other available evidence, Monitor”—

that is, NHS Improvement—

“is satisfied that the Board is failing to secure compliance with the Licensee’s licence conditions and failing properly to take steps to reduce the risk of non-compliance. In those circumstances, Monitor is satisfied that the governance of the Licensee is such that the Licensee is failing and will fail to comply with the conditions of its licence.”

On that basis, NHS Improvement, or Monitor, has imposed a new condition to Southern Health’s licence, requiring that it

“has in place sufficient and effective board, management and clinical leadership capacity and capability, as well as appropriate governance systems and processes, to enable it to”

address the failures in governance

“and comply with any enforcement undertakings, or discretionary requirements, imposed by Monitor in relation to these issues.”

[Kit Malthouse]

I am grateful to my hon. Friend for giving way to me for a second time.

One of the frustrations that I think we have all had throughout this sorry saga has been about the lack of any sense of personal responsibility or line management for particular risks. A thought occurs to me. Can my hon. Friend say who at NHS Improvement will take the decision about whether the trust should be given its licence? I ask that because I have a sense that unless we know who that person is, we will not be able properly to take a view about whether their judgment is right. If the decision disappears into a bureaucratic organisation, it may well never emerge in a timely fashion. Does she have an idea of who is responsible? If she does not, perhaps the Minister could let us know what the processes are regarding the taking of the decision and who finally gets to sign on the dotted line that everything is all right, or not.

[Suella Fernandes]

I agree that there is a real risk, as my hon. Friend says so eloquently, of this issue falling into a bureaucratic abyss. It is absolutely vital that we have clear processes and that the identities of the responsible people and professionals are clear, so that there is a clear line of accountability for users and indeed for MPs.

Following the resignation of Mike Petter as chairman of Southern Health, NHS Improvement exercised its power to intervene to appoint his replacement, Tim Smart, who is now acting as interim chairman. The notice directing the trust to appoint him stated:

“These matters demonstrate that the Licensee”—

that is, Southern Health—

“does not have in place sufficient or effective board management and clinical leadership capacity and capability, as well as appropriate governance systems and processes as required by additional licence conditions. Monitor is therefore satisfied that the Licensee is breaching the additional licence condition.”

Time and again, in report after report, Southern Health has been criticised for its failures of management and leadership, and the effects that those failures have had on the care that it provides. That is why I called for this debate that focuses on the governance of the trust. We all accept that, sadly, tragic failures in care will inevitably occur from time to time, and those at the top of an organisation cannot be held responsible for every incident on the frontline.

Equally, we must pay tribute to the dedicated staff of Southern Health for the excellent care that they give day in, day out for the majority of the time. We cannot and should not tar all of them with the same brush because of the failures of others. However, when clear and systematic problems have been identified, we are entitled to ask that lessons be learned. For me, the most shocking part of the sequence of events that I have just recounted is that right up until this year—indeed, even in the last couple of months—inspectors have stated that necessary changes that have been flagged up as needing action have not been implemented.

When NHS Improvement said in its enforcement notices that the trust was failing in its obligations under its licence and did not have effective border capacity and capability, it used the present tense. That was in April. Since then, Tim Smart has been installed as chairman, and I repeat my thanks to him for meeting my parliamentary colleagues and me yesterday in Westminster. He has been conducting an initial review of governance, and I was pleased to hear that he expects to make some announcements on his findings and proposals within the next month. I am sure I speak for many when I say that we will be looking for some far-reaching changes to recognise the gravity of the situation.

That brings me on to the issue of personnel. I have been asked repeatedly whether I am calling for the resignation of Southern’s executives, and in particular that of Katrina Percy, the chief executive. I have resisted doing so because, as the Minister has said in the House, politicians and Ministers demanding that heads must roll can often cause more problems than they solve. I repeat my thanks to Ms Percy and her team for coming to meet my colleagues and me on a number of occasions to answer our questions. However, I will now say publicly what I told her at our last meeting: I find it difficult to have confidence that she has properly acknowledged the scale of the problems under her leadership or how difficult it will be for patients and families to have their faith in the organisation restored without a visible sign of a fresh start.

Resignations are a matter for individuals, and Katrina Percy has said that she believes her responsibility is to provide stability by remaining in post. I understand that position, but the sheer weight of criticism of the trust’s leadership over a prolonged period while she has been chief executive would lead many to a different conclusion. The fact that NHS Improvement has now taken the power to direct changes at board level if it considers them necessary sends its own message.

[Mims Davies]

It has been my perception that there has been a sort of bunker mentality. Perhaps people are just burying their heads, going through the process and hoping it will go away. Does my hon. Friend agree that there is perhaps a little sense of that pervading Southern Health from the top?

[Suella Fernandes]

My hon. Friend is insightful in her observation, although I do not think it takes a genius to point it out. The catalogue of criticisms and failings is not new to anyone. I can understand the frustration and anger of families and patients when they feel that no substantive and material action is being taken.

A mechanism is now in place, and I hope the new chairman and the regulators from NHS Improvement will listen to what I and others say today and consider how they can best act to restore confidence in the trust. I thank my parliamentary colleagues for showing an interest, for speaking up for their constituents and for taking the time to voice their legitimate concerns, both directly to the professionals involved and in this debate.

Before I conclude, I again pay tribute to the families and campaigners who have pursued the issue and shared their experiences with us. In particular, the courage and resilience of Sara Ryan, Connor Sparrowhawk’s mother, has been an inspiration as she has continued to demand answers and ensure that the lessons of her son’s death are learned. Since the issue first began to attract significant coverage, more people have come forward with their own stories and added to the demands for action to be taken. They want to know that their concerns are being heard and that the Government and the NHS are serious about resolving the problems. I have heard them, and so has the Minister. I hope that he will be able to give them some of the reassurance they seek in his reply. I look forward to hearing from colleagues from all parts of the House.

[Several hon. Members rose—]

--- Later in debate ---

[Suella Fernandes]

Thank you for your chairmanship this afternoon, Mr Hanson. I am also grateful to the Minister for the time he spent meeting families and relatives today. I am confident that he understands the gravity of the problem, and that is reflected in his time, dedication and personal commitment to improving mental health throughout the country. I also acknowledge his apology, which will not change anything, but—I hope—might provide some solace.

The debate is for those we have lost, those let down by the professionals, those for whom help came too late and was too little, families and relatives: more widely, it is for all those with mental illness and learning disabilities. A nation is only as humane as its treatment of its most vulnerable. We here in the Chamber have a special duty to those who depend on healthcare and support. I hope that the debate marks the beginning of a journey towards more justice and compassion.

I am grateful to right hon. and hon. Members for their contribution to the issue and to the debate this afternoon.

Question put and agreed to.

Resolved,

That this House has considered governance of Southern Health NHS Foundation Trust.