0:00:04 > 0:00:07I'm a little concerned that you can't even put a plan together.
0:00:07 > 0:00:09That's so badly presented, that it doesn't look very good
0:00:09 > 0:00:11for the future to me.
0:00:11 > 0:00:14I want to know where to go to protest.
0:00:14 > 0:00:17We might do an investigation into that with our partners to s`y..
0:00:17 > 0:00:19Why doesn't your whistle-blowing policy announce the fact
0:00:19 > 0:00:20they can whistleblow?
0:00:20 > 0:00:24Mr Hill...
0:00:27 > 0:00:29It can't possibly be that difficult if you've got staff
0:00:29 > 0:00:30who are trained nurses.
0:00:30 > 0:00:33I am not responding to your personal case in a public forum.
0:00:33 > 0:00:36Even I can do a better job than you're doing right now...
0:00:36 > 0:00:40There are families ripped apart ..
0:00:40 > 0:00:42These are people, you should be investigating every single death
0:00:42 > 0:00:43that's not expected.
0:00:43 > 0:00:46It's outrageous, you know, you can't do this to people,
0:00:46 > 0:00:49that's why they feel so isolated and that's why your services aren't
0:00:49 > 0:00:51good, cos you really don't care about them.
0:00:51 > 0:00:53Everyone round this table, we do our jobs because we
0:00:53 > 0:00:56feel so strongly about offering good quality services to often
0:00:56 > 0:01:02some of the most vulnerable people in our society.
0:01:02 > 0:01:04There's a boss under fire...
0:01:04 > 0:01:06I get texts from people saying, there's TV
0:01:06 > 0:01:09cameras outside your house...
0:01:09 > 0:01:10..and fighting for her job.
0:01:10 > 0:01:13She reminds me of an Alan Stgar apprentice, quite honestly.
0:01:13 > 0:01:17There are days when I've thought I don't know if I can get up
0:01:17 > 0:01:19and carry on doing this.
0:01:19 > 0:01:22And there are mistakes that have cost lives.
0:01:22 > 0:01:26The carer hadn't had the tr`ining, he put his fingers up
0:01:26 > 0:01:28to his throat, and I said, no!
0:01:28 > 0:01:30Take your fingers off his throat.
0:01:30 > 0:01:34People are going to continud to die, because the systems they ard using
0:01:34 > 0:01:38and the management culture that operates is a cause of the problem.
0:01:38 > 0:01:41It's left a hole in my heart.
0:01:41 > 0:01:46And no-one will ever be able to replace that.
0:01:49 > 0:01:55We investigate the mental hdalth trust Southern Health.
0:02:07 > 0:02:12This man is going to the police
0:02:12 > 0:02:14Having thought about it, I decided to go and make a complaint
0:02:14 > 0:02:18to the police of harassment.
0:02:18 > 0:02:20He says Southern Health has bullied him,
0:02:20 > 0:02:26sent threatening letters, and damaged his health.
0:02:26 > 0:02:29I'd like the police to look at the evidence, and to go `nd have
0:02:29 > 0:02:32some words with them and to make it clear to the people
0:02:32 > 0:02:35whether or not their conduct is verging on the criminal.
0:02:35 > 0:02:39But he's not a patient - he's a Southern Health governor
0:02:39 > 0:02:42The worst they can do is sack me as a public governor.
0:02:42 > 0:02:43Am I afraid of that?
0:02:43 > 0:02:44No.
0:02:44 > 0:02:47If it means that it stops me speaking out,
0:02:47 > 0:02:50no, I'm sorry...
0:02:50 > 0:02:53My job is to listen to the public,
0:02:53 > 0:02:57to feed that back to the bo`rd, and also to feed to the public
0:02:57 > 0:03:01what's going on within their trust.
0:03:02 > 0:03:06This is the story of patients whose lives were put at risk,
0:03:06 > 0:03:11of warnings too easily ignored, and the unexpected deaths
0:03:11 > 0:03:15of hundreds of people.
0:03:15 > 0:03:22Peter Bell has called a public meeting about Southern Health.
0:03:22 > 0:03:25Peter says the trust tried to stop to meeting,
0:03:25 > 0:03:28something they deny.
0:03:28 > 0:03:32He's the only governor here.
0:03:32 > 0:03:34Just to let you know what's happening, um,
0:03:34 > 0:03:37the other governors were called by the chair to a meeting
0:03:37 > 0:03:40at Tatchbury Mount this morning at 9:30am,
0:03:40 > 0:03:43to be talked to.
0:03:43 > 0:03:46However, what I did say would happen is that we would continue
0:03:46 > 0:03:52with the meeting, so if it's just me, we'll record the mdeting,
0:03:52 > 0:03:59I'll make some notes and sole ents and we'll feed that back.
0:03:59 > 0:04:02I'll make some notes and sole comments and we'll feed that back.
0:04:02 > 0:04:04Many of these people have complaints against Southern Health.
0:04:04 > 0:04:05Some have taken legal action.
0:04:05 > 0:04:07It's dreadful misfortune that's actually brought us
0:04:07 > 0:04:10all here together, and the deaths of loved ones in the family
0:04:10 > 0:04:12that have brought us togethdr.
0:04:12 > 0:04:16But it's good that we've bedn able to do this and do something helpful
0:04:16 > 0:04:18to actually progress this dreadful situation.
0:04:19 > 0:04:21It was a crisis, not a...
0:04:21 > 0:04:24They treated her like a badly behaved young woman,
0:04:24 > 0:04:31who ended up in prison for being mentally unwell.
0:04:31 > 0:04:33Which is ridiculous.
0:04:33 > 0:04:35She was never charged with `nything, and it practically nearly
0:04:35 > 0:04:40destroyed our family, destroyed our family.
0:04:40 > 0:04:44If you speak to carers, if you speak to staff,
0:04:44 > 0:04:47if you speak to patients, nobody has confidence
0:04:47 > 0:04:52in the leadership that's there at the moment.
0:04:52 > 0:04:55So what is going on at Southern Health?
0:04:55 > 0:05:01Governors rebelling, patients dying, and families demanding change.
0:05:01 > 0:05:06We decided to start with the story of Edward Hartley.
0:05:06 > 0:05:07I think it's his smile that went before him.
0:05:14 > 0:05:16I think it's his smile that went before him.
0:05:16 > 0:05:20Everyone just adored his smile.
0:05:20 > 0:05:22He could light up a room.
0:05:22 > 0:05:26Edward lived a full life, as these family photos show.
0:05:26 > 0:05:30But he had a learning disabhlity and Dravet syndrome,
0:05:30 > 0:05:32a severe type of epilepsy.
0:05:32 > 0:05:36He could have 70 seizures a night.
0:05:36 > 0:05:38Nature of his condition was it always tended to happen
0:05:38 > 0:05:41during the sleeping hours and particularly if he was suddenly
0:05:41 > 0:05:45woken, if he was woken abruptly that would almost inevitablx
0:05:45 > 0:05:47trigger a seizure.
0:05:47 > 0:05:52But I don't think there was a single night went by when he didn't have
0:05:52 > 0:05:55some episode of some description.
0:05:55 > 0:06:01Every one of these seizures was a potential danger to hhm.
0:06:01 > 0:06:05So in 2014, Southern Health sent a carer to help
0:06:05 > 0:06:10look after him at home.
0:06:15 > 0:06:18One morning he left Edward `lone, and went into the kitchen
0:06:18 > 0:06:21where Jane was making breakfast
0:06:21 > 0:06:24When he returned to his post, this happened.
0:06:24 > 0:06:32I heard the carer shouting le, and saying Edward was a funny colour.
0:06:32 > 0:06:38Unfortunately the carer really, um, went to pieces,
0:06:38 > 0:06:45and I found Edward on his bdd, a very disturbing blue grey
0:06:45 > 0:06:50colour, and lifeless.
0:06:54 > 0:06:58I told the carer to get the phone and ring 999,
0:06:58 > 0:07:00but he couldn't do that,
0:07:00 > 0:07:07so I took over from that, and also carried out CPR,
0:07:07 > 0:07:12because the carer hadn't had the training,
0:07:12 > 0:07:15and I think it was a training issue all along, that the training
0:07:15 > 0:07:21hadn't been given, either in epilepsy care or CPR.
0:07:21 > 0:07:25And that's awful that he was put in that position.
0:07:25 > 0:07:30Edward had suffered a catastrophic epileptic sehzure.
0:07:30 > 0:07:35That must have been a very disturbing moment.
0:07:35 > 0:07:41Yes, yes, I mean, that's when our world crashed.
0:07:45 > 0:07:47Edward died that morning.
0:07:47 > 0:07:51He was 18 years old.
0:07:53 > 0:07:55This is one of the leavers' proms.
0:07:55 > 0:07:58Sadly, Edward didn't make his leavers prom.
0:07:58 > 0:08:00What his parents didn't know was that 12 months'
0:08:00 > 0:08:02before Edward's death,
0:08:02 > 0:08:06another young man with epildpsy died in Southern Health's care
0:08:06 > 0:08:08and the Trust was told to improve
0:08:09 > 0:08:12its resuscitation training.
0:08:12 > 0:08:15That young man was Connor Sparrowhawk, and his mother
0:08:15 > 0:08:19was to put a bombshell under Southern Health.
0:08:19 > 0:08:22Connor was left alone in a bath at a special unit.
0:08:22 > 0:08:26He had an epileptic seizure and drowned.
0:08:26 > 0:08:29It's incredibly hard to sort of think to yourself he was left
0:08:29 > 0:08:33to drown in a bath at hospital.
0:08:33 > 0:08:38It's probably something that'll just haunt us for the rest
0:08:38 > 0:08:41of our lives, I should think.
0:08:41 > 0:08:44Sara's campaign for a full investigation led to
0:08:44 > 0:08:46an independent review.
0:08:46 > 0:08:51Hundreds of investigated deaths were discovered.
0:08:51 > 0:08:52Hundreds of uninvestigated deaths were discovered.
0:08:52 > 0:08:54Vulnerable people, with learning difficulties
0:08:54 > 0:08:56and mental health problems.
0:08:56 > 0:08:59It was a catalogue of failure.
0:08:59 > 0:09:02Tonight at 10pm, the NHS Trtst heavily criticised for failhng
0:09:02 > 0:09:07to investigate the deaths of a more than 1000 people.
0:09:07 > 0:09:10Today marks the end of a two-year battle for justice by the f`mily
0:09:10 > 0:09:11of Connor Sparrowhawk.
0:09:11 > 0:09:14Since Connor's death Southern Health NHS Foundation Trust have
0:09:14 > 0:09:17consistently tried to duck responsibility.
0:09:17 > 0:09:20I am deeply, deeply sorry to Connor's family,
0:09:20 > 0:09:24his parents, his siblings, his wider family.
0:09:24 > 0:09:28We failed Connor in the most tragic way.
0:09:28 > 0:09:31Had the deaths been properlx investigated, lessons,
0:09:31 > 0:09:37like the lack of resuscitathon training, could have saved lives.
0:09:37 > 0:09:40I'm ashamed of you, and I'm definitely ashamed
0:09:40 > 0:09:44of Katrina Percy as well, who's meant to be the head
0:09:44 > 0:09:47and in charge of this organhsation.
0:09:47 > 0:09:49APPLAUSE.
0:09:49 > 0:09:51There was a national scandal.
0:09:51 > 0:09:54And the woman in charge was in the firing line
0:09:54 > 0:09:58from many people, including Connor's younger brother.
0:09:58 > 0:10:00I thought it extremely inappropriate that you would even say that
0:10:00 > 0:10:03you might have added to our grief as a family when
0:10:03 > 0:10:04you've definitely piled it on.
0:10:04 > 0:10:05All of you.
0:10:05 > 0:10:08And even in this two years, we still don't feel
0:10:08 > 0:10:10like we've got justice, and I don't know how you guxs
0:10:10 > 0:10:13can even still be here, but I'd like to see you try
0:10:13 > 0:10:16and defend yourselves with that and then I have a question
0:10:16 > 0:10:17after you've done that.
0:10:17 > 0:10:21We are all and myself personally and all of us are incrediblx sorry
0:10:21 > 0:10:27that the actions and the care allowed Connor to die.
0:10:27 > 0:10:29It was, what, 1% of learning difficulties
0:10:29 > 0:10:31deaths were investigated?
0:10:31 > 0:10:33To me, maybe I'm being naivd,
0:10:33 > 0:10:36but that looks like you don't care about people with learning
0:10:36 > 0:10:37difficulties nearly as much as anyone else.
0:10:37 > 0:10:39These are people you should be investigating every
0:10:39 > 0:10:41single death that's not expected, it's outrageous.
0:10:41 > 0:10:44You can't do this to people, that's why they feel so isolated
0:10:44 > 0:10:46and that's why your services aren't good, because you really
0:10:46 > 0:10:47don't care about them.
0:10:47 > 0:10:51We care for people, lots of people with learning disabilities
0:10:51 > 0:10:54lots of vulnerable elderly people, lots of people with mental health
0:10:54 > 0:10:58problems and that's why our staff come to work every day...
0:10:58 > 0:11:02Almost everyone wanted Katrina Percy sacked ?
0:11:02 > 0:11:10even some of her own governors.
0:11:10 > 0:11:13She reminds me of an Alan Stgar apprentice, quite honestly.
0:11:13 > 0:11:19I think someone who is promoted well out of her abilities to do the job
0:11:19 > 0:11:22I think someone who is promoted well out of her abilities to do the job,
0:11:22 > 0:11:24Is she capable of doing the job
0:11:24 > 0:11:28I don't think so, no, I think she's out of her depth.
0:11:28 > 0:11:32When Katrina Percy refused to resign, and became
0:11:32 > 0:11:35a national hate figure...
0:11:35 > 0:11:38It's been a bit strange.
0:11:38 > 0:11:44I've had people in my road, like, trying to interview me.
0:11:44 > 0:11:47I wanted to know how she coped with that.
0:11:47 > 0:11:50I was given unique access to her as she visited
0:11:50 > 0:11:56patients and staff.
0:11:56 > 0:11:58I think it's quite sad becatse it's not her personally that's done
0:11:58 > 0:12:01anything wrong, she's just trying to oversee everything,
0:12:01 > 0:12:04and mistakes are made, by everybody.
0:12:04 > 0:12:06I'm just trying to do the right thing for people.
0:12:06 > 0:12:10Cos you genuinely care.
0:12:10 > 0:12:14Personally, it's been reallx pressurised and really diffhcult,
0:12:14 > 0:12:17and there are days when I'vd thought, I don't know if I can get
0:12:17 > 0:12:19up today and carry on doing this.
0:12:19 > 0:12:20We've got Katrina here.
0:12:20 > 0:12:21Hi, David.
0:12:21 > 0:12:23Sorry I've descended on your house.
0:12:23 > 0:12:26Thank you ever so much.
0:12:26 > 0:12:28I'm watching what these guys do for their jobs today.
0:12:28 > 0:12:31I do the job because I care.
0:12:31 > 0:12:35And I want to do a good job, I'm someone who always wants to do
0:12:35 > 0:12:38well, do the best of my ability
0:12:38 > 0:12:41So to be faced constantly with people saying, you're not good
0:12:41 > 0:12:43at your job, you should go, you're not good enough
0:12:43 > 0:12:45is actually personally really quite hard for me,
0:12:45 > 0:12:50and gives you a bit of a crhsis of confidence I would say.
0:12:51 > 0:12:53You've got lovely legs, ha-ha-ha.
0:12:53 > 0:12:56You guys, you can tell you get on well as a team,
0:12:56 > 0:12:58and that you support each other
0:12:58 > 0:13:01It's a great team.
0:13:01 > 0:13:04I've cried at home a few tiles, but I've cried at work,
0:13:04 > 0:13:07it's been, just, it is almost when you're caught off guard
0:13:07 > 0:13:11by staff being so supportivd.
0:13:11 > 0:13:17That's given me a few tears.
0:13:17 > 0:13:19We've got a team dog walk tonight.
0:13:19 > 0:13:20Have you?
0:13:20 > 0:13:21Six o' clock.
0:13:21 > 0:13:23I can't go cos I'm going to see Rod Stewart.
0:13:23 > 0:13:27Are you?
0:13:27 > 0:13:30It probably sounds unfair to people who have lost, you know,
0:13:30 > 0:13:35what right do I have to cry, to people who've lost loved ones?
0:13:35 > 0:13:38It's nothing like that, but, but, it's been really, really
0:13:38 > 0:13:44difficult at times.
0:13:44 > 0:13:49Why do you keep coming in and doing the job ? why don't you just go ..
0:13:49 > 0:13:52I hope from what you've seen today, coming out with me today and seeing
0:13:52 > 0:13:57what my days are like that we've got amazing staff in this organhsation,
0:13:57 > 0:14:03we've got patients who rely on the things we do and support
0:14:03 > 0:14:08and care for them, and I re`lly care about us carrying on doing that
0:14:08 > 0:14:11So I think it's about trying to make sure that we're able
0:14:11 > 0:14:14to give that message around the good things we do,
0:14:14 > 0:14:19but also we do get things wrong ..
0:14:19 > 0:14:24But getting it wrong can cost lives.
0:14:24 > 0:14:26We found evidence that seriously ill patients have been able
0:14:26 > 0:14:33to kill themselves even in the most secure units.
0:14:33 > 0:14:35They used ligature points that Southern Health knew were d`ngerous,
0:14:35 > 0:14:38but did nothing about.
0:14:38 > 0:14:43Yet again, warnings were ignored, and patients died.
0:14:43 > 0:14:49Patients like Teresa Colvin.
0:14:49 > 0:14:54She was caring, funny, very meticulous.
0:14:55 > 0:15:00Loved her horses, loved dogs.
0:15:00 > 0:15:02Yeah, she was...
0:15:02 > 0:15:04She was a lovely person, absolutely lovely person.
0:15:04 > 0:15:06Teresa suffered from depression and psychosis,
0:15:06 > 0:15:08and in 2012, she went into Woodhaven Hospital,
0:15:08 > 0:15:11in Hampshire.
0:15:11 > 0:15:14She felt that by going into Woodhaven she would get that
0:15:14 > 0:15:17care and support and it would be the safest place for her,
0:15:17 > 0:15:20care and support and it would be the safest place for her,
0:15:20 > 0:15:23I think that was the, the main thing was that she felt it
0:15:23 > 0:15:25was the safest place for her to be.
0:15:25 > 0:15:29They let her down.
0:15:29 > 0:15:35With catastrophic results.
0:15:39 > 0:15:47On the 22nd of April, Teres`, TJ, hanged herself in a corridor.
0:15:47 > 0:15:49Jackie has still not been able to tell her children
0:15:49 > 0:15:53exactly how she died.
0:15:53 > 0:15:58TJ was not looked after properly,
0:15:58 > 0:16:05and she was able to have access to a ligature point,
0:16:05 > 0:16:08which had been recognised as being of danger to peopld
0:16:08 > 0:16:13who needed to be looked after and she was able
0:16:13 > 0:16:20to essentially asphyxiate hdrself.
0:16:20 > 0:16:26It's left a hole in my heart, um, and no one will ever be
0:16:26 > 0:16:32able to replace that.
0:16:32 > 0:16:34Southern Health could now face criminal charges
0:16:34 > 0:16:38over Teresa's death.
0:16:38 > 0:16:42This man has reported them to the Health and Safety Exdcutive.
0:16:42 > 0:16:44He'd warned Southern Health of the dangers,
0:16:44 > 0:16:48but they didn't listen.
0:16:48 > 0:16:51The nub of my warnings, was that Southern Health were not
0:16:51 > 0:16:54able to look after the safety of their patients ? that is right
0:16:55 > 0:17:01down to the nub of it.
0:17:01 > 0:17:04From what I had seen, it was inevitable that a patient
0:17:04 > 0:17:11would succeed in killing thdmselves.
0:17:11 > 0:17:16Two months before Teresa didd, Mike sent this email to Katrina Percy.
0:17:16 > 0:17:22He had found hundreds of ligature points inside mental health units.
0:17:22 > 0:17:28And a massive increase in the number of people trying to hang thdmselves.
0:17:28 > 0:17:32The number of ligature incidents, had increased five or six fold.
0:17:32 > 0:17:36So I think we started off whth 6 that were recorded, and I think
0:17:36 > 0:17:39we ended up with 470 to 500.
0:17:39 > 0:17:41So quite clearly that evidence that there was something
0:17:41 > 0:17:43that wasn't right.
0:17:43 > 0:17:44That's a huge increase.
0:17:44 > 0:17:46Massive increase.
0:17:46 > 0:17:50And of course every single one of those, although it might
0:17:50 > 0:17:52have been an incident, the fact it didn't end up
0:17:52 > 0:17:54with somebody either harming themselves or killing
0:17:54 > 0:18:00themselves in a lot of cases is a matter of luck.
0:18:00 > 0:18:02Instead of listening to Mikd, they refused to extend his
0:18:02 > 0:18:04contract ? so he quit.
0:18:04 > 0:18:10Did that make you angry?
0:18:10 > 0:18:12Anger, frustration at the, this is going nowhere,
0:18:12 > 0:18:22but absolute disappointment, despair, knowing that when xou walk
0:18:22 > 0:18:24away, there are patients behng cared for, who will because of thd
0:18:24 > 0:18:27very environment they're behng cared for in, will succeed
0:18:27 > 0:18:33in ending their life.
0:18:33 > 0:18:37He woke me up and he said, drm, Alison, James is dead.
0:18:37 > 0:18:39Two years after those warnings, James Younghusband hanged hhmself
0:18:39 > 0:18:49at Ravenswood House mental health unit.
0:18:49 > 0:18:52It quite clearly says there that James has implicitly stated
0:18:52 > 0:18:57that he would rather end his life than continue to feel this way.
0:18:57 > 0:19:01James was in a room full of ligature points.
0:19:01 > 0:19:06So whoever's filling this in, it's there for them to read.
0:19:06 > 0:19:08Why didn't they bother to rdad it?
0:19:08 > 0:19:11Why didn't they take notice?
0:19:11 > 0:19:13Why weren't they monitoring him correctly because they obviously
0:19:13 > 0:19:16weren't?
0:19:16 > 0:19:18And why didn't they take aw`y the ligature point that
0:19:18 > 0:19:22Mike Holder had warned them about?
0:19:22 > 0:19:25Mike had found 130 of them in the ward where James was staying,
0:19:25 > 0:19:27and once again, he told Southern Health bosses
0:19:27 > 0:19:32to sort it out.
0:19:32 > 0:19:34They omitted to tell us that there were ligature
0:19:34 > 0:19:35points in there.
0:19:35 > 0:19:37They were insisting that he was in a safe
0:19:37 > 0:19:43environment, but he wasn't.
0:19:43 > 0:19:47Even this year, 16 months l`ter inspectors found dangerous ligature
0:19:47 > 0:19:53points inside units putting patients' lives at risk.
0:19:53 > 0:19:55Southern Health says it's now appointed a ligature manager,
0:19:55 > 0:19:58and spent millions on the units
0:19:58 > 0:20:03It's confident the risks have been removed.
0:20:03 > 0:20:11But why weren't the clear w`rnings picked up much, much earlier?
0:20:11 > 0:20:18John Green believes it's thd way Southern Health and the NHS is run.
0:20:18 > 0:20:20The public might find it hard to believe but it operates
0:20:20 > 0:20:22like a totalitarian state.
0:20:22 > 0:20:24And so highly centralised, highly regulated, and
0:20:24 > 0:20:31an organisation that has enormous difficulty adapting to rapid change.
0:20:31 > 0:20:34People are going to continud to die, because the systems they're
0:20:34 > 0:20:36using and the management culture that operates is a cause
0:20:36 > 0:20:39of the problem.
0:20:39 > 0:20:43Like Peter Bell, the man who went to the police,
0:20:43 > 0:20:45John has spent months trying to change Southern Health
0:20:45 > 0:20:46from the inside.
0:20:46 > 0:20:50He failed, and now, he's speaking out.
0:20:50 > 0:20:54So I've been in there and I've spelt it out.
0:20:54 > 0:20:57I've gone as far as to say they're corrupt.
0:20:57 > 0:20:59Wow.
0:20:59 > 0:21:02Quite honestly I resigned, because I felt I was being corrupted
0:21:02 > 0:21:06by the organisation, in the sense that I was increasingly
0:21:06 > 0:21:12under pressure not to say what I felt was the truth.
0:21:12 > 0:21:15It's devious in what it trids to do, it behaves exactly as you would
0:21:15 > 0:21:19expect a dictatorship to behave and that deeply worries me.
0:21:19 > 0:21:21Corrupt is a strong word to use
0:21:21 > 0:21:24Yeah, I stick with that.
0:21:24 > 0:21:26I'd stick with that.
0:21:26 > 0:21:28I've heard that used by other people that
0:21:28 > 0:21:30work in the NHS.
0:21:30 > 0:21:33It's denial, cover-up.
0:21:33 > 0:21:37If that isn't corruption, what is?
0:21:37 > 0:21:39Neglect, failure to learn ldssons, and mistakes that cost lives.
0:21:39 > 0:21:43It's time to confront the boss.
0:21:47 > 0:21:56But it's not Katrina Percy ? because last week, she resigned
0:21:56 > 0:21:58The Chief Executive of Southern Health NHS Trust,
0:21:58 > 0:22:00one of the biggest mental hdalth trusts in the country,
0:22:00 > 0:22:03is stepping down.
0:22:03 > 0:22:06She's quit as head of a health trust criticised after the deaths
0:22:06 > 0:22:09of hundreds of patients but is kept on with the same salary.
0:22:09 > 0:22:15She's now giving strategic `dvice to GPs on nearly ?200,000 a year.
0:22:15 > 0:22:18And this man gave her the job.
0:22:18 > 0:22:24Did the new job exist before Katrina took it?
0:22:24 > 0:22:26The work needed to be done.
0:22:26 > 0:22:29Did that new job exist before Katrina took it?
0:22:29 > 0:22:31No.
0:22:31 > 0:22:36Did you advertise that job, so that other people could `pply?
0:22:36 > 0:22:41No. Was Katrina the only candid`te?
0:22:41 > 0:22:44She's uniquely qualified for it Was she the only candidate?
0:22:44 > 0:22:46Yes.
0:22:46 > 0:22:49To many people that will sound like a fix.
0:22:49 > 0:22:52But that is not the case.
0:22:52 > 0:22:59The role of a Chief Executive has multiple dimensions.
0:22:59 > 0:23:01I think people understand the role of a Chief Executive
0:23:01 > 0:23:04as being the person who is hn charge of an organisation and also
0:23:04 > 0:23:10the person who has to take responsibility when things go wrong,
0:23:10 > 0:23:12and she didn't take responsibility, did she?
0:23:12 > 0:23:19I think she did.
0:23:19 > 0:23:21The easy thing to do was to walk away.
0:23:21 > 0:23:24Is this a corrupt organisathon?
0:23:24 > 0:23:30No.
0:23:30 > 0:23:33Cover ups, mistakes, they don't tell the truth to families,
0:23:33 > 0:23:35don't listen when things go wrong.
0:23:35 > 0:23:40Oh, that's your definition of corrupt?
0:23:40 > 0:23:44And what about the harassment claims that sent Peter Bell to the police?
0:23:44 > 0:23:46Are you a bully?
0:23:46 > 0:23:49I've never been accused of being a bully.
0:23:49 > 0:23:52Well, you have now, by Peter Bell.
0:23:52 > 0:23:54So you tell me.
0:23:54 > 0:23:57That's his view and he's gone to the police with it.
0:23:57 > 0:23:59Every decision I'm making is made in the interests of the pathents
0:24:00 > 0:24:06and the families that we serve.
0:24:06 > 0:24:12When I meet bereaved families it hurts.
0:24:12 > 0:24:20It really hurts me, to meet people who have been failed.
0:24:20 > 0:24:26You might end up in court if the Health and Safety Exdcutive
0:24:26 > 0:24:29prosecute the Trust for the death of Teresa Colvin.
0:24:29 > 0:24:33If there are criminal chargds brought against this Trust
0:24:33 > 0:24:40because of a death of a pathent
0:24:40 > 0:24:43that is a really serious...there can't be a more serious matter.
0:24:43 > 0:24:45I agree with you.
0:24:45 > 0:24:51I'm not being blase, but so far no charges have been brought.
0:24:51 > 0:24:54There will be people going into Southern Health care
0:24:54 > 0:24:58today, tomorrow this week.
0:24:58 > 0:25:00Are they safe?
0:25:00 > 0:25:03Yes.
0:25:03 > 0:25:06I can unequivocally look you in the eye and say everx member
0:25:06 > 0:25:15of staff that I have met who works on the front line is putting patient
0:25:15 > 0:25:21safety and the quality of care first.
0:25:21 > 0:25:24Southern Health looks after 45, 00
0:25:24 > 0:25:26people with mental health problems and learning
0:25:26 > 0:25:30disabilities every year.
0:25:30 > 0:25:35Many with excellent results.
0:25:35 > 0:25:38I was in a very, very bad w`y.
0:25:38 > 0:25:42I was, I suppose people could be more ill that I was,
0:25:42 > 0:25:48but it's hard to imagine how much worse it could've been.
0:25:48 > 0:25:50Norman has spent nine weeks at a special unit,
0:25:50 > 0:25:51after planning to kill himsdlf.
0:25:51 > 0:25:54I'd been having thoughts for some time, and I'd actually
0:25:54 > 0:25:59formulated my plans.
0:25:59 > 0:26:06I'd composed letters to the coroner and to the police,
0:26:06 > 0:26:16detailing what had driven md to take my own life.
0:26:19 > 0:26:21Thank you for everything you've done, I can't thank
0:26:21 > 0:26:24you enough for everything.
0:26:24 > 0:26:26He's better now, thanks to the doctors and nurses
0:26:26 > 0:26:29at Southern Health.
0:26:29 > 0:26:35And he's leaving today.
0:26:35 > 0:26:37Small steps, and that's the way we have to do it.
0:26:37 > 0:26:40There is no giant step, just a series of small steps.
0:26:40 > 0:26:50Here we go.
0:26:53 > 0:26:55It's so good to see you.
0:26:55 > 0:27:00And you.
0:27:00 > 0:27:03There's this perception in society that we understand mental hdalth
0:27:03 > 0:27:05issues and people with ment`l health problems and we actually
0:27:05 > 0:27:08don't, I don't believe.
0:27:08 > 0:27:11It's not until you've experhenced it, the way I've experienced this,
0:27:11 > 0:27:16that you realise what mental health is all about.
0:27:16 > 0:27:23We tried to get a "welcome home but they didn't have one.
0:27:23 > 0:27:25I came here in complete despair with my dad,
0:27:25 > 0:27:32and they've rebuilt him, and they've given me back mx dad.
0:27:32 > 0:27:38Remember that ? that's official now.
0:27:38 > 0:27:40I promised you I'd come back for you.
0:27:40 > 0:27:43You did, when you brought md here you said I've brought
0:27:43 > 0:27:46you here today and one day H'll come back and take you home again.
0:27:46 > 0:27:49We're doing it, we're doing the last bit.
0:27:49 > 0:27:53This is the man I remember ? he s the man I remember that I'vd
0:27:53 > 0:27:54finally got back again.
0:27:54 > 0:27:55My dad.
0:27:55 > 0:27:57My hero.
0:27:57 > 0:28:02You take care, Peta.
0:28:02 > 0:28:07Every organisation makes mistakes.
0:28:07 > 0:28:09It's not learning from thosd mistakes that's the real crhme,
0:28:09 > 0:28:15but will things change?
0:28:15 > 0:28:16They must.
0:28:16 > 0:28:21Cor, that was emotional, wasn't it?
0:28:56 > 0:28:58If you've been affected by hssues raised in this programme,
0:28:58 > 0:29:03call the BBC Action Line, free and confidentially.
0:29:07 > 0:29:10Hello, I'm Tina Daheley with your 90 second update.
0:29:10 > 0:29:13The Paralympics kick off tonight in Rio with the opening ceremony
0:29:13 > 0:29:14at the Maracana Stadium.
0:29:14 > 0:29:17After a slow start, 1.6 million tickets have now been sold.
0:29:17 > 0:29:22Britain has 264 athletes taking part.
0:29:22 > 0:29:24Sports Direct boss Mike Ashley today said he needed more time
0:29:24 > 0:29:27to fix working conditions at his warehouses.
0:29:27 > 0:29:30He also pulled a wad of ?50 notes out of his pocket
0:29:30 > 0:29:32while showing journalists around!
0:29:32 > 0:29:35In the US, 13 women who say Bill Cosby drugged and sexually
0:29:35 > 0:29:38assaulted them have agreed to testify against him.
0:29:38 > 0:29:42The criminal case will be heard next year.
0:29:42 > 0:29:44This health boss had to resign after scores
0:29:44 > 0:29:46of deaths at her NHS Trust.