[Mr David Hanson in the Chair]
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.
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?
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”,
“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.
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?
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.
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.
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.”
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?
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.
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.
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.
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.
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.”
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.
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.
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?
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—
Order. Before I call the right hon. Member for Oxford East (Mr Smith), I should say that four hon. and right hon. Members have indicated that they wish to speak. I intend to call the shadow Minister at 3.35 pm and the Minister at quarter to 4 to give the hon. Member for Fareham (Suella Fernandes) a chance to wind up at the end. On that note, I hope Members will have self-restraint.
I congratulate the hon. Member for Fareham (Suella Fernandes) on securing this vital debate and on her work with the all-party group on Hampshire and Isle of Wight. Everything that has come out or been dragged out since the tragically avoidable death of Connor Sparrowhawk, “Laughing Boy”, has highlighted the severe failings of Southern Health and the wider questions they raise about the treatment of learning-disabled people in the NHS. The facts that have emerged are awful beyond belief and are a shocking indictment of the leadership of the Southern Health trust and the appalling neglect of the most basic care needs and human rights of learning-disabled people.
As the hon. Lady said, we all owe enormous thanks to the courage and determination of Connor’s mother, Sara Ryan, and her family, as well as the other families of those who have died and suffered. Without them, there was a real risk that the hideous truth of neglect at Southern Health might not have been fully exposed. Connor’s family and other families have been let down so badly and shamefully by Southern Health, which did not share information that the family had a right to. The family were treated as the enemy at Connor’s inquest and did not even receive an apology until Southern Health was directly pressed to give one. Even today, as Sara went for mediation with Southern Health on her human rights case, it had not released background papers, as it was supposed to have done.
The Mazars report happened only because of the determination and persistence of Connor’s family. As we have heard, the failings it exposed were shocking beyond belief and have been confirmed by the CQC reports. It is important to remember some of the hideous statistics that the hon. Lady quoted; we should remember that each one is a human life. Of 10,306 deaths, 722 were categorised as unexpected, of which only 272, or 37%, were investigated as a critical incident. A lower proportion—30%—of deaths in adult mental services were investigated. Appallingly, less than 1% of deaths in learning disability services were investigated. Liaison with families was appalling, with 64% of investigations not involving the family.
I will quote what the My Life, My Choice charity from my constituency said in a letter yesterday to the new chair of Southern Health. It is a charity of learning-disabled people, for learning-disabled people. This is how things look from the perspective of people with learning disabilities. It said:
“You suggested that the Mazars report was not very important, or not true. We think it is a very important report. Our members are very worried about people with learning disabilities dying, and their deaths not being properly looked into. We know from Connor’s case that the truth is not always told, so investigations need to happen. Our members are scared because people with learning disabilities do not get the same standard of healthcare as everybody else. The Mazars report told us that if we die, our deaths will not be taken seriously.”
Someone has to take responsibility for what happened. To the families and to the public, it is unbelievable that the chief executive and medical director of Southern Health are still in post. We all understand that due process has to be followed, but nearly three years on from Connor’s death, we must ask: how long will it take before those responsible are properly held to account? That is important not just to atone for a wrong; it is crucial because of the signal it sends to others responsible for the care of learning-disabled and other vulnerable patients. It is crucial in re-establishing public confidence that those leading the provision of care are responsible and are held responsible for their actions.
I look forward to the Minister’s response to this debate. With Sara Ryan I met the Secretary of State, and I have talked and corresponded with the Minister. I know that they too are both concerned to see matters put right at the trust, and to apply the lessons more generally in the healthcare system.
The right hon. Gentleman is making a powerful speech. His point that no one, no matter how vulnerable, should feel fear when they go into our health services is something that should give us all pause for thought in this Chamber. But it is not only about accountability in this case; it is also about making sure that those who are watching us as we go through the process know that an independent, verifiable process will be put in place so that nothing like this can ever happen again, not only at Southern Health but throughout our mental health services.
I very much agree with the hon. Lady, my neighbour and friend, on that important point. I look forward to the Minister’s response as to what the independent oversight will be to ensure security in future.
It will be helpful if the Minister can update us on progress in relation both to the Southern Health trust and to wider concerns in the NHS, and if he can say when he expects the CQC to publish its opinion on the trust’s response to its warning notice, with the possibility of enforcement action being taken. Will he also say when he expects the Government to be in a position to make a definitive statement on the action they will take on the conclusion of the Care Quality Commission’s wider investigation into deaths throughout the NHS? It is an enormously important issue to get right.
We all have to learn from these appalling events. We have to apply the lessons and put in place procedures and the culture so that learning-disabled people and others receive the care, treatment and respect that they deserve, and so that they can be confident that they will get that. An NHS that truly fulfils its duty of care, in which Southern Health so lamentably failed, is the only thing that can come close to a fitting memorial for Connor Sparrowhawk.
We can be more relaxed about the two remaining speakers because a Member who indicated that they wished to speak has now left.
My hon. Friend the Member for Fareham (Suella Fernandes) has done the House a service by bringing this debate to the Floor. The measure of cross-party support that she has achieved is evidenced by the powerful speech of the right hon. Member for Oxford East (Mr Smith).
I hesitated to contribute to this debate because I have not been involved in the cause of the current crisis, which is about the deaths of patients being insufficiently explained. However, I have a history with Southern Health. I explained in the course of an urgent question, which the present Minister responded to on 6 May, that back in 2011 and 2012 my dealings with the trust were, in 19 years in Parliament, the only constituency issue that caused me genuinely to suffer sleepless nights. It was a question not about the way in which people were treated as inpatients in Southern Health establishments, but about a determination by the trust, in concert with a number of other trusts in other parts of the country using similarly questionable techniques, to follow what appeared to be a trend, if not a fashion, to close a significant proportion—35%—of the existing inpatient acute mental health beds.
My hon. Friend the Member for Eastleigh (Mims Davies) said in her intervention that she detected something of a “bunker mentality”. She is absolutely right. The mentality that I detected at that time was a culture of stubbornness and denial about whatever it was that Southern Health wanted to do, irrespective of what other people might wish it to do. The issue at the time hinged upon something that ought to have been straightforward: namely, what was the necessary number of acute inpatient beds to retain. I raised that subject in two debates. Although I have not yet had the chance to meet Tim Smart, the new chairman of the trust, of whom I hear good reports, I hope he will take the opportunity to look up the two debates. One was on 10 November 2011 and, most importantly, the second one was on 18 April 2012. I had information from within the trust that the bed occupancy rates were high. In fact, the bed occupancy rates on average were between 91.9% and 96.7% when I was surveying the data. So it made it rather hard to argue that one could safely close two out of the six acute inpatient units, thus reducing the number of available acute inpatient beds from a total of 165 to only 107.
Part of the reason for the reduction was given quite frankly as a cost saving. It was proposed to save £4.4 million; £2.9 million out of that total would be absolute savings and the remaining £1.5 million would be invested in something called “hospital at home”. The group that we set up in the New Forest, which continues to meet regularly—usually three or four times a year—is called Support our Mental Health Services. It has found no evidence whatever that there has been any significant increase in the amount of support or the quality or quantity of support that people get at home.
Given that, at the time, with 165 beds 53% of patients were detained and just under half the total were people who opted to go into an acute bed if they suffered some dreadful breakdown, I predicted that the figure for those detained would rise proportionately to about 82%. When I made these remarks in public, Katrina Percy took objection to them and sent a letter to Ministers, councillors and Hampshire MPs denouncing my comments as “unfounded”, “scaremongering” and with “no place in the 21st century” because I had pointed out that if someone suffered a severe breakdown, perhaps their best chance of getting a bed if they needed one under the Southern Health regime would be to cause as much mayhem as possible. But it remains a fact that today, as I understand it from sources within the trust, some 80% of the remaining beds are occupied by people who have been sectioned or detained, and that means that the opportunity for getting a bed if you need one, other than if you are sectioned, is correspondingly reduced.
The difficulty that I had at the time in trying to save the beds was that the trust’s clinical director, Dr Lesley Stevens, was determined to go on repeating figures over and over again that there were between 20 and 30 beds vacant at any one time. There were not. Exceptionally, in a short period—if I remember correctly around Christmas time—there was a figure of that sort, but even by the time she was continuing to put that bogus figure forward, that temporary departure from the norm of high bed occupancy had already been left behind and we were back to business as usual with pressure on bed numbers. Eventually, even a proposal that instead of closing both units at once the trust should close just one of the two units scheduled for closure, and see how that panned out, was rejected.
As you can imagine, Mr Hanson, the relationship between me and the trust was pretty much at rock bottom after all the controversy, but both sides decided we had better try to make the best of what was now a fait accompli. Katrina Percy, for her part, promised—and I believe she kept the promise—that no patient whom the trust judged to be really in need of a bed would be denied one, even if one had to be bought in from the private sector. In return I volunteered never to criticise the trust if it bought in such beds; and I never have, because it is most important that it should give beds to those who need them, and that it should not be deterred because of a politician saying “I told you so; look, you are now having to buy in private beds.”
To bring the story up to date, and conclude: there was a double tragedy. The individual tragedy was the death of a young man called James Barton. He was taken on by the trust and became the director of mental health and learning disabilities. That was in about 2014, and in my opinion James was a total breath of fresh air. He reached out to us, and said, “I know we have had all these troubles in the past; I want to build a new relationship”—and he did. In the course of a number of times when James came to liaise with and participate in our group he confided to me that he believed that the bed cutting had gone too far, and he was experimenting with different configurations, in the hope that bringing perhaps about 15 or 18 beds back into the system—approaching approximately half of what had been lost—might get things back into balance. Tragically, in February 2015 James was suddenly found dead at the age of 36, from an unexplained medical condition. That was a huge personal loss to people such as myself, who knew him only slightly. I can only imagine the catastrophic loss it was to his nearest and dearest.
It was also a tragedy from the point of view of people who need acute beds, in my opinion. Although James’s successor, Mark Morgan, has maintained the contact and is a very pleasant person to deal with, the message that I am getting back from Southern Health now is exactly what it was: “Well, we were having to buy in these beds, but we are not having to do it now, and we seem to be back in balance. We don’t need any extra beds.” Incidentally, one of the two units that were closed was at Woodhaven hospital and was only eight years old. I had performed the opening ceremony. The Winsor ward in Woodhaven hospital remains empty to this day.
I have had families coming to see me—particularly the families of people aged 19 or in their early 20s—for whom beds and in-patient availability are the biggest issue. The treatment at home is working, but they need more sustained treatment, and the closure of bed spaces is having a profound effect on the development of those young people.
Furthermore, the beds at Woodhaven were state of the art, with en suite facilities—which is terribly important if someone has to be an in-patient in such circumstances. Many of the remaining beds do not have those facilities. That ward has been standing empty for several years now. I believe a change of culture is needed in the trust. Certainly there is no difference of opinion between us on the point that it is desirable if possible for people to avoid going into a mental health unit as an in-patient. However, to have the confidence to be treated in the community they must know that there will be in-patient beds for the occasions when they need extra support. I hope that that lesson from the past will be borne in mind in future restructuring of the trust. I called the trust’s culture one of stubborness and denial. That may lie in the minds of individuals, rather than in its structure, but that is a matter for people other than me to decide.
It is a pleasure to serve under your chairmanship, Mr Hanson. I congratulate my hon. Friend the Member for Fareham (Suella Fernandes) on securing this important debate, and I join her in paying tribute to the families, friends and campaigners who have followed this cause since the very beginning of the tragic chronology that she outlined. My right hon. Friend the Member for New Forest East (Dr Lewis) has just given a very eloquent speech. I propose to take the House through a short episode involving a constituent of mine, David Hinks.
However, I should start by noting that the issue is of cross-party interest—the right hon. Member for Oxford East (Mr Smith) is here—and that it crosses the geographic boundaries of Hampshire and Oxfordshire, and other areas covered by Southern Health’s geographic remit. I pay tribute to the Minister for taking the issue so seriously and look forward to welcoming him to Havant tomorrow to talk about mental health issues. I know that he takes the issue seriously, and I look forward to his response.
David Hinks was 30 years old, and he lived in Bedhampton in Havant. He worked as a ticket inspector for South West Trains, and he had a history of mental illness, which included no fewer than five suicide attempts. However, despite that mental health history, he was never admitted to a psychiatric ward. He was offered only antidepressants and group therapy sessions, which fell well short of the treatment and support that he needed. In 2015, he was arrested by the police on suspicion of assaulting his wife. However, despite that quite drastic step, Southern Health again took no immediate action, and sent someone round to his house to check on him in December 2015 a few days after he had committed suicide.
That is just one of the many tragic cases presided over by Southern Health in recent years. My hon. Friend the Member for Fareham has recounted many others. There has been great public interest in the issue in the Havant constituency, particularly around the time of the Mazars report and the recommendations for action by the CQC. I call on the Minister to do all he can to ask NHS Improvement to recommend improvements in the procedures of Southern Health—particularly in relation to risk reporting procedures, staff training and safeguarding procedures. All MPs have among their constituents some of the most vulnerable members of society, and we rely on institutions such as Southern Health to take good care of them in their time of need. I hope that David Hinks’s death will not have been in vain. Improvements must come and lessons must be learned. I know that the Minister will take Mr Hinks’s case as seriously as the others that he has heard about.
I join others in welcoming Tim Smart as the new interim chair of Southern Health, and I thank him for his engagement, as I do Katrina Percy, who is based in my constituency. The issue is one of substantial public concern throughout the area covered by Southern Health. I hope that the debate will be a catalyst for those who are working hard to change the culture and improve the service, and I look forward to further reports to the House.
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.
It is a pleasure to serve under your chairmanship, Mr Hanson. I thank my hon. Friend the Member for Fareham (Suella Fernandes) for securing this important debate on the governance of the Southern Health NHS Foundation Trust. I also thank all Members who have spoken, by way of either significant speeches or interventions. The number of colleagues from the area who are involved—from across the House—gives an indication of how seriously we all take this issue. I urge the trust’s representatives to read the report of this debate extremely carefully, so that they absorb everything said by my hon. Friend and all those who have spoken in support.
May I begin by once again apologising to all the patients and families who have been affected by the failure of the trust to provide safe care for its patients? I met Sara Ryan yesterday when I visited the National Forum of People with Learning Disabilities. I had an opportunity to have a conversation with her, and I met more parents and families today before the start of this sitting. Nothing that an official can write on a piece of paper can adequately describe what it is like to meet and talk to families who have been involved in the sort of things that we are talking about here. This is not the first time I have had such meetings: I have had them since coming into post a year ago. It is impossible to convey simply and straightforwardly all that people feel.
What worries me most—I have said this to families in private and I say it again here—is that I hear the same things again and again. I hear about the frustration and concern about the time taken to get anything done when it has been agreed that something should be done, about the time taken to get any answers about what might be done in the first place, and about the defensiveness in the attitude of the institution being dealt with—my hon. Friend the Member for Eastleigh (Mims Davies) described it as a bunker mentality. I do not know whether it is a reflection of a professional attitude—because clinicians and others see things every day—but it is genuinely upsetting to hear people who have lost their loved ones talk about the lack of simple sympathy from those who deal with them. I have heard from enough people in enough different parts of the country to know that what I am hearing is not a one-off.
I also get distressed when I hear through the system that people can be difficult. People have every reason to be difficult, but that is not an acceptable way of describing people who are concerned and upset.
Because this point is made in place after place, as the hon. Member for Liverpool, Wavertree (Luciana Berger) knows well, by many different types of people, I am not sure that the system’s response deals adequately with some of the individual issues that have arisen over the past year—I will come to that later. I say to the parents and families involved that their individual contact, when they get the opportunity, with Members of Parliament and Ministers is not time wasted. It is easy to say that people will feel that only when they see something done, but the contact has a profound impact on officials and Ministers alike.
The first duty of any care provider is to keep its patients safe. The reports of inaction, bordering on complacency, set out in the recent Care Quality Commission report were truly shocking. I responded to an urgent question on the safety of care and services at the trust on 3 May, and I welcome the opportunity provided by today’s debate to update the House on the actions taken in response, several of which pick up on issues raised by the hon. Member for Liverpool, Wavertree and others.
As hon. Members are aware, NHS England commissioned a review by Mazars in November 2014 of deaths of people with a learning disability or mental health problem in contact with the trust between April 2011 and March 2015, in response to serious concerns surrounding the avoidable death of Connor Sparrowhawk. On publication of the report in December 2015, my right hon. Friend the Secretary of State for Health asked the Care Quality Commission to carry out a focused inspection of the trust to review its governance arrangements and its approach to investigating and learning from incidents, as well as its progress in responding to Monitor’s action plan.
On 12 January, Monitor announced further regulatory action in response to the Mazars report, including the appointment of an improvement director for the trust. The CQC inspection took place in January 2016 and led to a warning notice and an announcement of further regulatory action by NHS Improvement, which were both published on 6 April 2016. On 5 May, following the resignation of the trust’s chair, Mike Petter, NHS Improvement required the trust to appoint Tim Smart as the new interim chair. Those actions were in response to the persistent failure of the trust’s senior management to address the environmental and governance risks identified by CQC as far back as October 2014.
The hon. Member for Liverpool, Wavertree and others asked about what has been happening. The issue is split into looking at what has happened and—to use that terribly clichéd phrase—what lessons can be learned, and what is happening now and what confidence people can have in the future. That is vitally important.
I have sought assurances from NHS Improvement and CQC that the regulators are now able to oversee a rapid programme of remedial action by the trust, and I understand that the following measures are now in place. First, at monthly progress review meetings, NHS Improvement challenges the trust’s death and incident reporting action plan and its progress. Secondly, at the request of NHS Improvement, the death and incident reporting action plan is currently subject to external scrutiny. Thirdly, Alan Yates, the improvement director, is acting as a direct link from the trust to NHS Improvement, providing support and constructive challenge to the trust’s board in its oversight of the implementation of the action plan and providing assurance to NHS Improvement and other stakeholders about the trust’s approach.
On the work being done to bring the governance question to a swift conclusion, and in answer to the hon. Lady’s question about pace, the interim chair has already overseen improvements to clinical governance and the trust’s response to the CQC warning notice and NHSI licensing conditions. In parallel, he has commissioned an external review of the capability of the board, which extends to executive and non-executive directors and will inform a decision on leadership by 6 July. That will give the chair, whom I met a couple of days ago, the opportunity to review current capabilities with a view to the future. It is important that he has done that.
Tim Smart has also been in discussion with clinical commissioning groups and other trusts across the local health economy about the provision of services in accordance with the NHS five year forward view, and what that might mean for Southern Health. The transfer of the learning disability service in Oxford to Oxford Health will have been completed by the middle of October.
I spoke to Tim yesterday, and I am absolutely clear that he is right to insist on the highest standards of governance, with leadership concentrating on the real business of the trust—patients and their care. We have an imminent deadline, processes are in place and I am confident that a better Southern Health will emerge, but my confidence counts for very little. It is important that I am able to say that to colleagues with confidence, but the real confidence Southern Health has to gain is that of its patients and families and those who are involved. Having met some of them today, I know that that is a difficult hurdle to overcome, but it is the most important one. A description of processes and what people such as me are doing is not sufficient.
It is necessary that I have said what I have said to colleagues, and that I put on the record that I am confident that NHS Improvement’s review process and its ability to make management and executive changes—which will be carried out by Tim Smart, a newly appointed, experienced chair—is a good response to what has happened. The right person is in place with the power and ability to make the necessary decisions, but any confidence in them will come from the quality of the actions taken as a consequence of the powers invested in the chair and NHS Improvement. Unless actions that have the confidence of people are seen to be taken, something will be lacking. It is important that the chair’s judgment is relied on at this stage, and that I am able to reassure colleagues that the way in which NHS Improvement is working with the chair, and the powers that it and CQC have, are appropriate at the present time, but we must see what happens next.
The Minister opened by expressing his frustration that, since taking his post, he has been hearing about similar failings again and again. Of course, it is not just us in this place who hear about those failings, but the public and patients too. Every time they do, they lose confidence in the ability of the health service and the Government to address those failings. What in the steps that the Minister and Southern Health are proposing will break that mould? What will be different about the response this time? How will our response to this crisis restore the confidence of our most vulnerable constituents?
I will address that a little later, if I may, but I will come to it.
I should also answer the right hon. Member for Oxford East (Mr Smith) on the chain of accountability for NHS Improvement, and on who makes the decisions there. The decisions are made by Jim Mackey, who leads NHS Improvement. He is a direct appointment of the Secretary of State, so the Secretary of State invests his confidence in Mr Mackey, who makes the decisions on the work of NHS Improvement.
I will now turn to some of the issues raised by my hon. Friend the Member for Fareham and others. First, on the position of Katrina Percy, I need to be clear: Ministers have no authority to intervene in such matters, and nor would it be right for them to do so. I have been assured by Jim Mackey, the chief executive of NHS Improvement, that agreed processes are in place to review the performance of the senior leadership team and to make any changes that are in the best interests of patients. A Minister has to leave that there, and is not able to express any further view. That there is confidence in decisions taken is clearly of huge importance to Members in the Chamber, as they have expressed, and to others. A process is in place to decide that, and it will be decided by the chair.
I share my hon. Friend’s concern that inspectors have pointed to repeated failure by the trust to close out necessary improvement actions until the beginning of the year. NHS Improvement has asked the improvement director to ensure that the trust does not treat actions as complete until sufficient robust evidence supports that claim. The repeated failure to complete actions is one of the things that I will come on to in answer to my hon. Friend’s questions. When people are told what to do by a serious regulator, why do they not just do it? Why do they not do it in Southern Health, but do it in other places? What is the point of accountability and what is the process whereby in other parts of public service something is demanded by a regulator—say, in the acute part of the NHS—and something therefore happens, but something does not happen if dealing with those with mental health or learning disability issues?
Yesterday, Mr Smart told me that his initial view on exactly this point was that the senior executive team had a focus on dealing with Southern Health’s public relations issues, and not really on the care and quality in what was being delivered. That, simply, was why there was no change.
My hon. Friend makes her own point about a conversation I was not part of. I am sure people will read what she has to say.
As I have already set out, a clear and robust process is being taken forward by the interim chair to review the capability of the board and to take any necessary action. My hon. Friend the Member for Fareham has called for far-reaching changes. I ask that we await the conclusions of the review and look for the right balance to be struck between continuity and stability to ensure that the trust is able to deliver what it has promised. Wholesale change could introduce further delays to making progress on such work.
Recent media reports have suggested that the trust might be split up. I repeat that the priority now is to ensure safe and effective care in the present and in the future for the population served by Southern Health. NHS Improvement is working with the trust to explore all available options.
Members have also asked why the trust has not been prosecuted for historic safety breaches. I am aware of the allegations of historic health and safety breaches made by a former health and safety advisor to the trust, who has also briefed CQC about such concerns. I share the concerns of all those who are asking why it has taken so long to get a grip on the issues. CQC did indeed identify safety concerns back in October 2014 and has provided an assessment of safety in its most recent report. However, it is unforgivable that patients have continued to be exposed to unnecessary risk while the trust has dragged its feet in resolving the problems.
I understand that CQC has now reviewed evidence gathered during the most recent inspections and additional information obtained from the trust and other public bodies, including the Health and Safety Executive. CQC’s review has identified further lines of inquiry, which it plans to complete as quickly as possible in order to inform a decision on prosecution one way or the other.
Is it not the case that following the gathering of that further evidence and, indeed, of other leaked reports of what Southern Health knew at an earlier stage, which had not previously been apparent, the police are now reviewing the case for prosecution?
Genuinely, I am unaware of that. The police may review evidence at any time. If CQC has certain evidence that it wishes to take to the police for prosecution, that is a matter for it. I understand the processes that people would want to go through. It is important for me to offer reassurance that those processes are in place, and that things that for too long have been swept under the carpet are open for examination, which I understand to be the case.
Let me deal with the question of a public inquiry. Ministers face many calls for inquiries, and it is important for public inquiries to be considered only where other available investigatory mechanisms would not be sufficient. Public inquiries are rare events. I argue that the processes now being followed by NHS Improvement and CQC are the best way to put right the safety and governance issues at Southern Health. That does not rule out the dissemination of wider learning from this case through NHS Improvement or, where appropriate, the holding to account of individuals via professional regulation or normal performance management routes.
It is right and proper that we should ask such questions. We can perhaps examine whether the system would have responded in the same way had the trust been an acute trust, as I mentioned earlier. I am passionate about improving the care and outcomes for people with mental illness or learning disabilities by ensuring that all aspects of healthcare for people, whatever the issue that has brought them into the care of the NHS and others, are given equal priority with physical health. That must include regulation.
Let me now deal with the point made by my hon. Friend the Member for Oxford West and Abingdon (Nicola Blackwood). As I have indicated, what I have observed over the past year has worried me. That is to say, there seems to be greater tolerance of when things go wrong in mental health than in acute services. We need to ask ourselves why it has taken so long to resolve those difficulties and to reach the regulatory decisions that are now starting to take effect.
I will therefore be looking at the matter with NHS Improvement, to consider both the effectiveness and the timeliness of regulatory interventions in mental health and learning disability services. I am keen to bring independent leadership into that work, alongside NHS Improvement. A task-and-report group will do a piece of work specifically on that.
Let me name the other places that have upset me during the course of the year. In Hull, there has been a problem with in-patient beds and an inability on the part of the NHS to make decisions about it for more than three years. There was the case of Matthew Garnett, the young man with autism in the wrong place; I could not get information on him for weeks, because of the failure of the NHS to provide what I needed. There are the problems in Tottenham with new mental health facilities, similar to what happened in York, at Bootham Park—how that was closed, and the inability of people to handle it correctly. That is a whole series of cases in which I think things could have been done better. The response has not been good enough. An inquiry into one thing is not sufficient, and the processes are in place to deal with that. Looking at the whole range of why such things happen is really important, and that work is now underway.
Will the Minister give way?
No, I cannot, because my hon. Friend the Member for Fareham has to have her two minutes.
A further review of the investigation of deaths is being done. It was announced by my right hon. Friend the Secretary of State for Health, but it will not be completed until the end of the year, when the Department will give its response. This has been a hugely important debate, but it is not the end of the matter. It is a staging post, and people will be able to see things following it. I commend my hon. Friend for raising it.
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.
That this House has considered governance of Southern Health NHS Foundation Trust.