"This is the story of how the #NHS failed to question why hundreds of patients died unexpectedly... a trust that didn't talk to families, was not interested in learning lessons... senior managers who failed to do their jobs"
2/
Featuring interview with Tessa Summers parents, she died aged 20 in 2013
"there's lots of people involved paid to do a job and they didn't do it" Jim Lynock, Tessa's stepfather
Nearly 1,200 unexpected deaths not investigated over previous 4yrs
3/
"There is no reason why in 2015 a report like this should come out, no reason at all, the Board and the senior team are completely responsible for this, utterly shameful" @sarasiobhan
"Without a doubt. They should have gone already, they've read the report" @sarasiobhan
@BBCMBuchanan describes the report as a damning inditement of one of the country's largest #mentalhealth trusts... a failure of leadership @Southern_NHSFT, a lack of transparency
5/
@BBCMBuchanan introduces Katrina Percy as the woman now in the firing line, Mazars report said the "failure to bring about sustained improvement in the identification of unexpected deaths is a failure of leadership and of governance"
6/
How did @Southern_NHSFT respond? By complaining about the report of course...
The report authors had said they had "little confidence that the Trust has fully recognised the need for it to improve its reporting and investigation of deaths"
7/
"What really worries me is there appears to be no sense that the trust is learning, that they're changing their practice and I think in the light of this report there has to be some accountability here, someone has to be held to account, at a senior level" @normanlamb
8/
Everyone else could see it for what it was, the failings of the CEO and her brazen denial and deflection, her refusal to take responsibility or show any leadership, for what it was.
Two more bereaved parents were spoken to by @BBCMBuchanan
Mandy Park who's daughter, Hannah Groves died in 2012, aged 20 and @Richard39450952 Richard West, who's son, David, died in 2013 aged 28. A member of the trust described David's death as "like losing baggage"
12/
Next day, 11 Dec 2015 @BBCMBuchanan caught up with Katrina Percy
"A failure of leadership was blamed... but Katrina Percy says she's not resigning... she went on to criticise the report's authors saying they'd not properly understood the data"
This was of course a totally baseless accusation by Katrina Percy, perhaps she hadn't understood the data, after all it was big numbers, something that she clearly struggled to keep under control - more on that in a little while.
14/
Julie O'Shaughnessy's son Mark killed himself while under the care of @Southern_NHSFT The trust acknowledged they could have provided more support.
Julie wants Katrina Percy to resign
"I think watching Katrina Percy's interview, its despicable..."
15/
"Katrina Percy's defiant attitude today, refusing to resign, attacking the authors of the report, may have to change in the coming days.... when the full details are revealed it's hard to imagine there wont be new leadership @Southern_NHSFT"
In a truly breathtaking interview after the Mazars Report was published, on 17 Dec 2015, Katrina Percy said this:
"We're really sorry to anybody who loses a loved one, and its really sad whenever a loved one dies, and all of us have experienced that" bbc.co.uk/news/av/health…
17/
She cont'd:
"and we know its a very difficult time and we're very upset and sorry to say that we might have added to that grief by not investigating appropriately... my job is to continue to lead this organisation"
Despite numerous bereaved relatives asking her to resign
18/
"Extremely inappropriate that you would even say that you might have added to our grief as a family, when you've definitely piled it on, all of you" Tom
19/
"The Trust told the meeting however, that no-one would resign" that was Jan 2016 bbc.co.uk/news/av/health…
April 2016 Board Chair, Mike Petter, resigned ahead of publication of damning CQC report. Katrina Percy continues to claim she's indispensable bbc.co.uk/news/av/health…
20/
May 2016 and the new Chair of the Board, Tim Smart, cancelled a meeting where a vote of no confidence in the Board was expected bbc.co.uk/news/uk-englan…
June 2016 Tim Smart claimed he's conducted an extensive review, not sure how extensive given it lasted just 6 weeks
21/
He concluded that the @Southern_NHSFT executive team had been "too stretched to guarantee high quality services"... that Katrina Percy had been "too operationally focused" but he'd found no "evidence of negligence or incompetence" by any board member
"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"
23/
Finally, a month later, in August 2016, Katrina Percy resigned as CEO, due to "media attention", apparently...
"Katrina Percy has finally accepted what most people concluded months ago, that her position was untenable... " reported @BBCMBuchanan
Amarnih died aged 24, in April 2021. She fell to her death. The jury could not be certain whether she intended to die.
Amarnih had been on a waiting list to access a gender identity clinic for over 2.5yrs at the time of her death. The coroner identified five related concerns
2/
Benjamin Hart was 25 when he died by suicide in October 2022. His care plan said he'd see a care coordinator weekly after discharge from hospital, he saw them 3 times in 6mths. He had no contact from the CMHT for 5wks before his death.
3/
Here's all eleven 2023 Prevention of Future Death Reports I could find for learning disabled people.
Lugh Baker, 24, died April 2021 [Open conclusion]
David Hemmings, 71, died June 2021 [following complications of surgery as a result of an accidental fall in his home]
1/14
Owen Garnett, 19, died January 2023 [Misadventure, after swallowing paper towel while unsupervised at school. Concerns of his carers were not acted on]
Steven Duquemin, 'relatively young age', died August 2022 [accidental death, after choking on raw chicken overnight]
2/
Matthew Dale, 43, December 2020 [Misadventure in part contributed to by a missed opportunity to increase supervision to meet Matthew's needs, after he swallowed and choked on some of his incontinence pad]
Claire Twinn, 47, December 2022 [Natural causes, bronchopneumonia]
3/
2021: 2.5% employees with a learning disability
2020: not reported
2019: 4% employees disabled, of which 2% had a learning disability
2018: 3.6% of which 1.9%
2017: 1.4% of which 1.2%
2016: 1.7% of which 1.1%
2015: 2.7% of which 0.9%
2014: 3% of which 1.1%
Woeful
2/
It's all well and good telling the world that people with a learning disability make great employees, this from the 2020 report, the one that doesn't say how many people with a learning disability @mencap_charity employee, but if so why not employ them?
This has had the best legal minds on it, I'm not doubting their skill or ability, but I can't wrap my head around so much in this case and the Supreme Court's judgement. Jackie Maguire was deprived of her liberty, in a
If #socialcare truly had parity with healthcare I wonder if the same conclusions would be reached.
I note in the judgement learning difficulties and learning disabilities are used interchangeably, which is deeply problematic given they mean different things.
2/
Jackie, had complained of sporadic stomach pain for two months before her death [Para 68] but an ultrasound wasn't able to be performed in Dec 2016 as she was upset.
There appears to have been no further interrogation of what could have been done to change that situation.
3/
This has had the best legal minds on it, I'm not doubting their skill or ability, but I can't wrap my head around so much in this case and the Supreme Court's judgement.
Jackie Maguire was deprived of her liberty, in a @unitedresponse care home.
1/
If #socialcare truly had parity with healthcare I wonder if the same conclusions would be reached.
I note in the judgement learning difficulties and learning disabilities are used interchangeably, which is deeply problematic given they mean different things.
2/
Jackie, had complained of sporadic stomach pain for two months before her death [Para 68] but an ultrasound wasn't able to be performed in Dec 2016 as she was upset.
There appears to have been no further interrogation of what could have been done to change that situation.
3/