I’m training for #CaminoLB at the moment which mostly involves wandering around in walking boots and a rucksack, putting one foot in front of the other and musing the latest madness at Southern Health. There’s been a lot of musing this week (although slightly less walking) as the latest development has seen Katrina Percy, CEO at Southern Health ‘step down’ from her role. It’s unclear whether Katrina just can’t admit to herself (even now) that she’s failed in her role and that is why she’s ‘stepping down’ not resigning it, or whether that belies some other corrupt twist that makes it easier for her to be slotted into a new role, in the same Trust, on the same salary and benefits, with no recruitment process. Nothing like transparency, nope, nothing like it.

Why is Katrina stepping down?

It is not because in her tenure as CEO she:

Ignored the advice of Mike Holder, the Health and Safety expert appointed after a staff member wrote to her concerned about patient safety. Mike resigned warning the Trust that their ‘existing safety management systems are dysfunctional’ and when asked for more information he provided a 12 page report detailing all the risks and failings.

Note: They knew of failings five years ago. Mike was asked to provide more information, the Board were aware, Katrina Percy knew and dismissed his concerns in 2011.

Nor is it because she:

Acquired Ridgeway LD Trust and ignored all the concerns raised in the due diligence reports conducted by Contact Consulting and their internal staff member John Stagg, insisting on a flawed ‘business as usual’ approach. A document leaked to #JusticeforLB in 2016 showed Stagg’s report clearly identified a series of failings at the STATT Unit where LB died in July 2013, that were replicated when the CQC went into the unit in response to his death in September.

Note: They knew, Southern Health Board knew there were failings at the STATT Unit, they didn’t address these before or after LB died there. Their failure to address them led to the unit being issued with a warning notice on every domain assessed that led to it being closed down. Katrina Percy and the Board made that decision in 2013.

Nor is it because the first two key findings of the Mazars report were:

There was a lack of leadership, focus and sufficient time spent in the Trust on carefully reporting and investigating unexpected deaths of Mental Health and Learning Disability service users.

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

Note: They knew, Southern Health Board and Katrina Percy chose to investigate and fixate on (money linked) pressure ulcers, and ignore the information they were receiving about patient deaths. Coroners contacted them, Prevention of Future Death reports were written, the system was awash with failings, they knew.

Nor is it because she set a culture, by continually painting herself as an aggrieved party, that led to a staff member leaving a voicemail on Sara’s phone stating:

I do think you are being very vindictive. I think you are a vindictive cow.

On TV all the time, ummm, slating the NHS Southern Health. With your intelligent background, you know, as much as much as anyone else knows, that Southern Health only took over those units in Oxfordshire recent, you know the recent months before your son died.

You know, with your background, it takes a while to make changes in anywhere.

Note: If it sounds familiar it’s because it is what Katrina has been peddling internally since LB died, that it was an unfortunate one off (it always is in the NHS) and that no-one understood how poor Ridgeway was, no-one allowed them time to improve things. Let’s not forget their tardy behaviour cost LB his life. You can listen to the call here.

Nor is it because of questionable payments to Katrina’s chums:

One firm received more than £5m despite winning a contract valued at less than £300,000, while another was paid more than £500,000 without bidding at all.

Both are owned by former acquaintances of Southern Health NHS Trust’s chief executive Katrina Percy.

Note: The Trust statement in response to this coverage was focused on dismissing the relationship between Katrina and the bidders, not the complete farce that is spending half a million without even pretending to tender for it, or £300k turning into £5million. Of course one has to ask why the lady doth protest so much about her ‘relationships’.

Katrina is ‘stepping down’ because she doesn’t like scrutiny, or in her words:

the effect the ongoing personal media attention has had on staff and patients and have come to the conclusion that this has made my role untenable

Wow, just wow. The complete erasure of any history, of any responsibility, of any accountability.

No mention of the ligature point warnings that led to more patients dying in the ways that had been warned; no mention of the due diligence ignored that led to LB’s death; no mention of her shame that your death had a 0.3% chance of being investigated if you were over 65 and used mental health services, and 1% chance if you had a learning disability; no mention of the utterly appalling contempt that Katrina Percy has shown for bereaved family members.

No, Katrina has reflected and come to the conclusion that the media are to blame.

The pesky journalists digging around, examining evidence, not just singing from her (delusional?) hymn sheet. It is quite a show of ego (and at this stage no surprise) that Katrina’s reflections extend no further than herself.

Defending the indefensible

HSJ ran a story on Katrina Percy ‘stepping down’ this week, and Minh Alexander tweeted a snapshot of reader responses:

HSJ readers' comments on La Percy. The anthropology of NHS denial.https://t.co/fB0EtnWtdX @Meg_HillierMP #LordsQs pic.twitter.com/oD3VXKAsKe

— Minh Alexander (@alexander_minh) September 1, 2016

The continual defence of the indefensible.

It reminds me of my time in Ireland when the Catholic Church was facing scrutiny and investigation into paedophile priests, but people could not help but defend their own. Fact, evidence and personal testimony swept aside by religious zeal and a complete ‘faith’ in those elevated to positions of power. True to the goings on of the Catholic Church, Katrina Percy has been moved to a new parish, in fact not even moved to a new parish, just moved to a new role within the same parish. With the same access and power and salary, who cares about those who suffer as a result of her failings? We’re in peak denial here and nothing will budge us.

The commentators above highlight risk to future leaders, blame the media, wheel out an efficiency and waste argument (did I mention Katrina is keeping her quart of a million benefits and salary package in her new non-role), humanity, admire KP’s courage, blame the non-Execs, rewrite history.

Scrutiny and holding the Board to account 

So what of the HSJ comment writer who blamed the non-Execs for failing to hold Katrina and her Board to account. It seems that there is always someone else to blame when things go wrong in the NHS. Katrina Percy had dug her heels in years before LB died, she had already dismissed Mike Holder’s evidence and expertise, she started with a culture where she knew best and no-one who questioned or scrutinised that would be tolerated. Patient safety, pah, patient deaths, pah. Patients, who cares about patients?

The truly sad thing about all of this is that it was so predictable. Back at the end of 2011 the Chair of Southern Health resigned after just one term in post. This week the Chair’s letter pinged it’s way anonymously into the virtual Justice Shed (I am so grateful to those who continue to provide us with yet more evidence, never seems to count for much, but it does stop us going slowly mad). This resignation letter was sent to NHS Improvement (then Monitor) and shows how the CEO responded to anyone trying to scrutinise the care they provided. The letter clearly lists the failings and challenges and personal perspective of the outgoing Chair, detailing why they felt their post was untenable. It includes:

‘The first issue has related to the Chair’s involvement, visibility and approachability. As a Non Executive Chair it has been important for me to seek independent assurance and take a patient and carer’s perspective through attending service user and care group meetings, and also a staff’s view from programmed visits and attending Trust events. I have made a point of getting out and about in the Trust, meeting with Governors on a regular basis and external networking with partner organisations and I think this has helped me be more secure in the information I am given and better placed to challenge. As a result staff, external stakeholders and patient and carers feel able to speak to me and do so. The current CEO and more than 50% Board (using the Deloitte test) believe I may be too visible within the Trust, too approachable and that staff talk to me inappropriately and have as a result tended to dismiss much of what I have fed back as “snap shots” e.g. reverse takeover feelings, qualms about office moves, Ashford Unit safety issues, impact of “disappearance” of many MH and LD staff”

Imagine a Chair that was approachable, that people felt able to talk to, who cared enough to seek assurances from patients and staff. Imagine accusing your Chair of being too approachable and too visible. Why would anyone want to shun such an approach, unless of course they don’t like scrutiny because they’re already out of their depth. In 2011.

This letter was sent to Paul Streat, the Relationship Manager at Monitor who was responsible for Southern Health. It will come as no shock at this stage to know that Paul Streat no longer works for NHS Improvement (perhaps due to their failings to hold Southern Health to account or improve things), no Paul has moved on…. to the post of Director of Provider Development, at Southern Health.

It’s so sordid and lacking in candour, honesty or transparency you couldn’t make it up. I’ve got no pithy ending, no request, no hope. As long as those with power in the NHS stand by and defend the indefensible, as long as NHS Improvement allow this farce to continue, there is no accountability and there can be no improvement. But who cares about patients anyway?

For more on the early failings of Southern Health Board check out this timeline of early years failings on the JusticeforLB site.

For a list of ongoing failings, their consequences and the impact on families see Richard West’s statement here.