Southern Health NHS Foundation Trust

Kit Malthouse Excerpts

Wednesday 8th June 2016 Westminster Hall

[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.

--- Later in debate ---

[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.