Broken Trust

I'm a little concerned that you can't even put a plan together.

That's so badly presented, that it doesn't look very good

for the future to me.

I want to know where to go to protest.

We might do an investigation into that with our partners to s`y..

Why doesn't your whistle-blowing policy announce the fact

they can whistleblow?

Mr Hill...

It can't possibly be that difficult if you've got staff

who are trained nurses.

I am not responding to your personal case in a public forum.

Even I can do a better job than you're doing right now...

There are families ripped apart ..

These are people, you should be investigating every single death

that's not expected.

It's outrageous, you know, you can't do this to people,

that's why they feel so isolated and that's why your services aren't

good, cos you really don't care about them.

Everyone round this table, we do our jobs because we

feel so strongly about offering good quality services to often

some of the most vulnerable people in our society.

There's a boss under fire...

I get texts from people saying, there's TV

cameras outside your house...

..and fighting for her job.

She reminds me of an Alan Stgar apprentice, quite honestly.

There are days when I've thought I don't know if I can get up

and carry on doing this.

And there are mistakes that have cost lives.

The carer hadn't had the tr`ining, he put his fingers up

to his throat, and I said, no!

Take your fingers off his throat.

People are going to continud to die, because the systems they ard using

and the management culture that operates is a cause of the problem.

It's left a hole in my heart.

And no-one will ever be able to replace that.

We investigate the mental hdalth trust Southern Health.

This man is going to the police

Having thought about it, I decided to go and make a complaint

to the police of harassment.

He says Southern Health has bullied him,

sent threatening letters, and damaged his health.

I'd like the police to look at the evidence, and to go `nd have

some words with them and to make it clear to the people

whether or not their conduct is verging on the criminal.

But he's not a patient - he's a Southern Health governor

The worst they can do is sack me as a public governor.

Am I afraid of that?

No.

If it means that it stops me speaking out,

no, I'm sorry...

My job is to listen to the public,

to feed that back to the bo`rd, and also to feed to the public

what's going on within their trust.

This is the story of patients whose lives were put at risk,

of warnings too easily ignored, and the unexpected deaths

of hundreds of people.

Peter Bell has called a public meeting about Southern Health.

Peter says the trust tried to stop to meeting,

something they deny.

He's the only governor here.

Just to let you know what's happening, um,

the other governors were called by the chair to a meeting

at Tatchbury Mount this morning at 9:30am,

to be talked to.

However, what I did say would happen is that we would continue

with the meeting, so if it's just me, we'll record the mdeting,

I'll make some notes and sole ents and we'll feed that back.

I'll make some notes and sole comments and we'll feed that back.

Many of these people have complaints against Southern Health.

Some have taken legal action.

It's dreadful misfortune that's actually brought us

all here together, and the deaths of loved ones in the family

that have brought us togethdr.

But it's good that we've bedn able to do this and do something helpful

to actually progress this dreadful situation.

It was a crisis, not a...

They treated her like a badly behaved young woman,

who ended up in prison for being mentally unwell.

Which is ridiculous.

She was never charged with `nything, and it practically nearly

destroyed our family, destroyed our family.

If you speak to carers, if you speak to staff,

if you speak to patients, nobody has confidence

in the leadership that's there at the moment.

So what is going on at Southern Health?

Governors rebelling, patients dying, and families demanding change.

We decided to start with the story of Edward Hartley.

I think it's his smile that went before him.

I think it's his smile that went before him.

Everyone just adored his smile.

He could light up a room.

Edward lived a full life, as these family photos show.

But he had a learning disabhlity and Dravet syndrome,

a severe type of epilepsy.

He could have 70 seizures a night.

Nature of his condition was it always tended to happen

during the sleeping hours and particularly if he was suddenly

woken, if he was woken abruptly that would almost inevitablx

trigger a seizure.

But I don't think there was a single night went by when he didn't have

some episode of some description.

Every one of these seizures was a potential danger to hhm.

So in 2014, Southern Health sent a carer to help

look after him at home.

One morning he left Edward `lone, and went into the kitchen

where Jane was making breakfast

When he returned to his post, this happened.

I heard the carer shouting le, and saying Edward was a funny colour.

Unfortunately the carer really, um, went to pieces,

and I found Edward on his bdd, a very disturbing blue grey

colour, and lifeless.

I told the carer to get the phone and ring 999,

but he couldn't do that,

so I took over from that, and also carried out CPR,

because the carer hadn't had the training,

and I think it was a training issue all along, that the training

hadn't been given, either in epilepsy care or CPR.

And that's awful that he was put in that position.

Edward had suffered a catastrophic epileptic sehzure.

That must have been a very disturbing moment.

Yes, yes, I mean, that's when our world crashed.

Edward died that morning.

He was 18 years old.

This is one of the leavers' proms.

Sadly, Edward didn't make his leavers prom.

What his parents didn't know was that 12 months'

before Edward's death,

another young man with epildpsy died in Southern Health's care

and the Trust was told to improve

its resuscitation training.

That young man was Connor Sparrowhawk, and his mother

was to put a bombshell under Southern Health.

Connor was left alone in a bath at a special unit.

He had an epileptic seizure and drowned.

It's incredibly hard to sort of think to yourself he was left

to drown in a bath at hospital.

It's probably something that'll just haunt us for the rest

of our lives, I should think.

Sara's campaign for a full investigation led to

an independent review.

Hundreds of investigated deaths were discovered.

Hundreds of uninvestigated deaths were discovered.

Vulnerable people, with learning difficulties

and mental health problems.

It was a catalogue of failure.

Tonight at 10pm, the NHS Trtst heavily criticised for failhng

to investigate the deaths of a more than 1000 people.

Today marks the end of a two-year battle for justice by the f`mily

of Connor Sparrowhawk.

Since Connor's death Southern Health NHS Foundation Trust have

consistently tried to duck responsibility.

I am deeply, deeply sorry to Connor's family,

his parents, his siblings, his wider family.

We failed Connor in the most tragic way.

Had the deaths been properlx investigated, lessons,

like the lack of resuscitathon training, could have saved lives.

I'm ashamed of you, and I'm definitely ashamed

of Katrina Percy as well, who's meant to be the head

and in charge of this organhsation.

APPLAUSE.

There was a national scandal.

And the woman in charge was in the firing line

from many people, including Connor's younger brother.

I thought it extremely inappropriate that you would even say that

you might have added to our grief as a family when

you've definitely piled it on.

All of you.

And even in this two years, we still don't feel

like we've got justice, and I don't know how you guxs

can even still be here, but I'd like to see you try

and defend yourselves with that and then I have a question

after you've done that.

We are all and myself personally and all of us are incrediblx sorry

that the actions and the care allowed Connor to die.

It was, what, 1% of learning difficulties

deaths were investigated?

To me, maybe I'm being naivd,

but that looks like you don't care about people with learning

difficulties nearly as much as anyone else.

These are people you should be investigating every

single death that's not expected, it's outrageous.

You can't do this to people, that's why they feel so isolated

and that's why your services aren't good, because you really

don't care about them.

We care for people, lots of people with learning disabilities

lots of vulnerable elderly people, lots of people with mental health

problems and that's why our staff come to work every day...

Almost everyone wanted Katrina Percy sacked ?

even some of her own governors.

She reminds me of an Alan Stgar apprentice, quite honestly.

I think someone who is promoted well out of her abilities to do the job

I think someone who is promoted well out of her abilities to do the job,

Is she capable of doing the job

I don't think so, no, I think she's out of her depth.

When Katrina Percy refused to resign, and became

a national hate figure...

It's been a bit strange.

I've had people in my road, like, trying to interview me.

I wanted to know how she coped with that.

I was given unique access to her as she visited

patients and staff.

I think it's quite sad becatse it's not her personally that's done

anything wrong, she's just trying to oversee everything,

and mistakes are made, by everybody.

I'm just trying to do the right thing for people.

Cos you genuinely care.

Personally, it's been reallx pressurised and really diffhcult,

and there are days when I'vd thought, I don't know if I can get

up today and carry on doing this.

We've got Katrina here.

Hi, David.

Sorry I've descended on your house.

Thank you ever so much.

I'm watching what these guys do for their jobs today.

I do the job because I care.

And I want to do a good job, I'm someone who always wants to do

well, do the best of my ability

So to be faced constantly with people saying, you're not good

at your job, you should go, you're not good enough

is actually personally really quite hard for me,

and gives you a bit of a crhsis of confidence I would say.

You've got lovely legs, ha-ha-ha.

You guys, you can tell you get on well as a team,

and that you support each other

It's a great team.

I've cried at home a few tiles, but I've cried at work,

it's been, just, it is almost when you're caught off guard

by staff being so supportivd.

That's given me a few tears.

We've got a team dog walk tonight.

Have you?

Six o' clock.

I can't go cos I'm going to see Rod Stewart.

Are you?

It probably sounds unfair to people who have lost, you know,

what right do I have to cry, to people who've lost loved ones?

It's nothing like that, but, but, it's been really, really

difficult at times.

Why do you keep coming in and doing the job ? why don't you just go ..

I hope from what you've seen today, coming out with me today and seeing

what my days are like that we've got amazing staff in this organhsation,

we've got patients who rely on the things we do and support

and care for them, and I re`lly care about us carrying on doing that

So I think it's about trying to make sure that we're able

to give that message around the good things we do,

but also we do get things wrong ..

But getting it wrong can cost lives.

We found evidence that seriously ill patients have been able

to kill themselves even in the most secure units.

They used ligature points that Southern Health knew were d`ngerous,

but did nothing about.

Yet again, warnings were ignored, and patients died.

Patients like Teresa Colvin.

She was caring, funny, very meticulous.

Loved her horses, loved dogs.

Yeah, she was...

She was a lovely person, absolutely lovely person.

Teresa suffered from depression and psychosis,

and in 2012, she went into Woodhaven Hospital,

in Hampshire.

She felt that by going into Woodhaven she would get that

care and support and it would be the safest place for her,

care and support and it would be the safest place for her,

I think that was the, the main thing was that she felt it

was the safest place for her to be.

They let her down.

With catastrophic results.

On the 22nd of April, Teres`, TJ, hanged herself in a corridor.

Jackie has still not been able to tell her children

exactly how she died.

TJ was not looked after properly,

and she was able to have access to a ligature point,

which had been recognised as being of danger to peopld

who needed to be looked after and she was able

to essentially asphyxiate hdrself.

It's left a hole in my heart, um, and no one will ever be

able to replace that.

Southern Health could now face criminal charges

over Teresa's death.

This man has reported them to the Health and Safety Exdcutive.

He'd warned Southern Health of the dangers,

but they didn't listen.

The nub of my warnings, was that Southern Health were not

able to look after the safety of their patients ? that is right

down to the nub of it.

From what I had seen, it was inevitable that a patient

would succeed in killing thdmselves.

Two months before Teresa didd, Mike sent this email to Katrina Percy.

He had found hundreds of ligature points inside mental health units.

And a massive increase in the number of people trying to hang thdmselves.

The number of ligature incidents, had increased five or six fold.

So I think we started off whth 6 that were recorded, and I think

we ended up with 470 to 500.

So quite clearly that evidence that there was something

that wasn't right.

That's a huge increase.

Massive increase.

And of course every single one of those, although it might

have been an incident, the fact it didn't end up

with somebody either harming themselves or killing

themselves in a lot of cases is a matter of luck.

Instead of listening to Mikd, they refused to extend his

contract ? so he quit.

Did that make you angry?

Anger, frustration at the, this is going nowhere,

but absolute disappointment, despair, knowing that when xou walk

away, there are patients behng cared for, who will because of thd

very environment they're behng cared for in, will succeed

in ending their life.

He woke me up and he said, drm, Alison, James is dead.

Two years after those warnings, James Younghusband hanged hhmself

at Ravenswood House mental health unit.

It quite clearly says there that James has implicitly stated

that he would rather end his life than continue to feel this way.

James was in a room full of ligature points.

So whoever's filling this in, it's there for them to read.

Why didn't they bother to rdad it?

Why didn't they take notice?

Why weren't they monitoring him correctly because they obviously

weren't?

And why didn't they take aw`y the ligature point that

Mike Holder had warned them about?

Mike had found 130 of them in the ward where James was staying,

and once again, he told Southern Health bosses

to sort it out.

They omitted to tell us that there were ligature

points in there.

They were insisting that he was in a safe

environment, but he wasn't.

Even this year, 16 months l`ter inspectors found dangerous ligature

points inside units putting patients' lives at risk.

Southern Health says it's now appointed a ligature manager,

and spent millions on the units

It's confident the risks have been removed.

But why weren't the clear w`rnings picked up much, much earlier?

John Green believes it's thd way Southern Health and the NHS is run.

The public might find it hard to believe but it operates

like a totalitarian state.

And so highly centralised, highly regulated, and

an organisation that has enormous difficulty adapting to rapid change.

People are going to continud to die, because the systems they're

using and the management culture that operates is a cause

of the problem.

Like Peter Bell, the man who went to the police,

John has spent months trying to change Southern Health

from the inside.

He failed, and now, he's speaking out.

So I've been in there and I've spelt it out.

I've gone as far as to say they're corrupt.

Wow.

Quite honestly I resigned, because I felt I was being corrupted

by the organisation, in the sense that I was increasingly

under pressure not to say what I felt was the truth.

It's devious in what it trids to do, it behaves exactly as you would

expect a dictatorship to behave and that deeply worries me.

Corrupt is a strong word to use

Yeah, I stick with that.

I'd stick with that.

I've heard that used by other people that

work in the NHS.

It's denial, cover-up.

If that isn't corruption, what is?

Neglect, failure to learn ldssons, and mistakes that cost lives.

It's time to confront the boss.

But it's not Katrina Percy ? because last week, she resigned

The Chief Executive of Southern Health NHS Trust,

one of the biggest mental hdalth trusts in the country,

is stepping down.

She's quit as head of a health trust criticised after the deaths

of hundreds of patients but is kept on with the same salary.

She's now giving strategic `dvice to GPs on nearly ?200,000 a year.

And this man gave her the job.

Did the new job exist before Katrina took it?

The work needed to be done.

Did that new job exist before Katrina took it?

No.

Did you advertise that job, so that other people could `pply?

No. Was Katrina the only candid`te?

She's uniquely qualified for it Was she the only candidate?

Yes.

To many people that will sound like a fix.

But that is not the case.

The role of a Chief Executive has multiple dimensions.

I think people understand the role of a Chief Executive

as being the person who is hn charge of an organisation and also

the person who has to take responsibility when things go wrong,

and she didn't take responsibility, did she?

I think she did.

The easy thing to do was to walk away.

Is this a corrupt organisathon?

No.

Cover ups, mistakes, they don't tell the truth to families,

don't listen when things go wrong.

Oh, that's your definition of corrupt?

And what about the harassment claims that sent Peter Bell to the police?

Are you a bully?

I've never been accused of being a bully.

Well, you have now, by Peter Bell.

So you tell me.

That's his view and he's gone to the police with it.

Every decision I'm making is made in the interests of the pathents

and the families that we serve.

When I meet bereaved families it hurts.

It really hurts me, to meet people who have been failed.

You might end up in court if the Health and Safety Exdcutive

prosecute the Trust for the death of Teresa Colvin.

If there are criminal chargds brought against this Trust

because of a death of a pathent

that is a really serious...there can't be a more serious matter.

I agree with you.

I'm not being blase, but so far no charges have been brought.

There will be people going into Southern Health care

today, tomorrow this week.

Are they safe?

Yes.

I can unequivocally look you in the eye and say everx member

of staff that I have met who works on the front line is putting patient

safety and the quality of care first.

Southern Health looks after 45, 00

people with mental health problems and learning

disabilities every year.

Many with excellent results.

I was in a very, very bad w`y.

I was, I suppose people could be more ill that I was,

but it's hard to imagine how much worse it could've been.

Norman has spent nine weeks at a special unit,

after planning to kill himsdlf.

I'd been having thoughts for some time, and I'd actually

formulated my plans.

I'd composed letters to the coroner and to the police,

detailing what had driven md to take my own life.

Thank you for everything you've done, I can't thank

you enough for everything.

He's better now, thanks to the doctors and nurses

at Southern Health.

And he's leaving today.

Small steps, and that's the way we have to do it.

There is no giant step, just a series of small steps.

Here we go.

It's so good to see you.

And you.

There's this perception in society that we understand mental hdalth

issues and people with ment`l health problems and we actually

don't, I don't believe.

It's not until you've experhenced it, the way I've experienced this,

that you realise what mental health is all about.

We tried to get a "welcome home but they didn't have one.

I came here in complete despair with my dad,

and they've rebuilt him, and they've given me back mx dad.

Remember that ? that's official now.

I promised you I'd come back for you.

You did, when you brought md here you said I've brought

you here today and one day H'll come back and take you home again.

We're doing it, we're doing the last bit.

This is the man I remember ? he s the man I remember that I'vd

finally got back again.

My dad.

My hero.

You take care, Peta.

Every organisation makes mistakes.

It's not learning from thosd mistakes that's the real crhme,

but will things change?

They must.

Cor, that was emotional, wasn't it?

If you've been affected by hssues raised in this programme,

call the BBC Action Line, free and confidentially.

Hello, I'm Tina Daheley with your 90 second update.

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