DO NOT ALLOW MERGER!!!!!!!! Written evidence from Mr & Mrs Cowling (CAL 23) THE PRESENT COMPLAINTS SYSTEM DOES NOT WORK—READ ON —— We have followed the NHS complaints process but have had no remedy. — The death of our daughter resulted in a Coroner's Rule 43 applied to South Essex Partnership Mental Health Trust (SEPT) in March 2010. — We know that other patient s have died and as well as a member of the public as result of a homicide by a patient who was supposed to be under the care of South Essex Partnership NHS Trust. These were preventable deaths if people had received the appropriate care, treatment and monitoring from this Trust. — South Essex Partnership NHS Mental Health Trust failed to listen to our concerns and did not review adequately the substance of our complaint and the Serious Untoward Incident Report was not given the necessary attention. — We have not had an apology from the Trust which continues the harm and distress already caused. — There are echoes of "Baby P" and reckless governance by this Trust, similar to the findings of Robert Francis in the Mid Staffordshire Inquiry. However, this has been a deliberate strategy of SEPT, self promotion at the expense of patient safety. — There is evidence of manipulation of the self assessment system in place at the time that resulted in cash bonuses paid to the Chief Executive and other employees, which is tantamount to fraud. — The Chief Executive had been part of the investigating team into the failings of West London Mental Health Trust. — http://www.sept.nhs.uk/Boards-and-Members/Board-Meetings/~/media/SEPT/Files/Board%20Papers/Governor%20Minutes/BoG%202009%20Nov.ashx The BoG had been advised that a report would be received on behalf of the BoD following a seminar meeting of SEPT's response to the failings at West London Mental Health Trust. However, LC said she gives her assurance that Dr Patrick Geoghegan, Chief Executive (PG) was on the panel of the London investigation, he would have certainly already implemented any changes needed. LC advised governors will be updated once the report is done. — The above assurances were false, he had not implemented changes or recognised the deficiencies in our daughter's SUI hence patients remained at risk. This is indicative of a lack of robust scrutiny by Trust governors, a concern highlighted again by Robert Francis at the Mid Staffordshire Inquiry. — There has been lack of compliance with the NHS code of conduct for managers as we know that false information has been passed onto the monitoring bodies on a number of occasions to provide assurance which we know has been false. — The monitoring bodies appear to be impotent and suggest that the relationships are too "cosy" and do not appear robustly objective, in particular, we are concerned about the Care Quality Commission. — South West Essex PCT recognised that it had relied on the concept of "good faith" to the detriment of patient safety. — The Parliamentary Health Service Ombudsman ( PHSO), despite awareness of our hardship and resulting illnesses caused by our distress and despair due to the loss of our daughter and our concerns regarding patient safety, declined to investigate. — On obtaining Freedom of Information from the PHSO regarding our case, it was clear that there was a complete lack of clinical expertise in reviewing our case with an unreasonable "Wednesbury" decision making process. — PHSO does not have patient safety at the heart of its principles which is a serious flaw. — As only 2% of complaints are investigated by the PHSO, what happens to the remaining 98%? Like us, there is no remedy. — There is a lack of data regarding safety and quality in mental health provision and this should be addressed. Patient suicides should be considered "never" events. — There is a lack of choice of providers of care for patients suffering from mental health conditions and therefore we are unable to use local services. — This Trust was allowed to expand, further diminishing patient choice (imagine Mid-Staffordshire taking over another acute Trust!). — An independent investigation should be carried out to ensure that investigations have been carried out properly and that lessons are indeed learned, otherwise patient safety cannot be guaranteed under this Trust's leadership. 1. Our 19 year old daughter died whilst a patient of South Essex Partnership MHT (SEPT) in March 2008. Her Inquest in March 2010 resulted in a Coroner's Rule 43 applied to this Trust: http://www.justice.gov.uk/publications/docs/third-summary-coroners-reports-rule43a.pdf 2. The Trust subsequently engaged lawyers in an attempt to launch a Judicial Review of the verdict on the basis that the Trust had increased the likelihood of her death rather then caused it! We are pleased to say that the futility of this action was recognised and further waste of taxpayers' money was avoided. 3. "I'm the first to say we have to hold up our hands if we get things wrong..." http://www.guardianpublic.co.uk/patrick-geoghegan-dudman 4. This statement is false; we have not received an apology. If the harm has not been acknowledged, then patients remain at risk. 5. On obtaining our daughter's medical records it was clear that the Care Programme Approach (CPA) was not adhered to nor were a number of Trust Policies and Procedures. It was also clear that National Guidelines regarding risk highlighted by the Confidential Inquiry into Suicide and Homicide and appropriate treatment as advocated by NICE guidelines were not being followed. The many professionals who saw her kept separate records; she was never seen with full information despite signing a sharing information agreement. On reading the "Baby P" tragedy, we could draw similar parallels of poor communication and system failure. It was also apparent that following two high profile homicides under HSG(94)27 that Action Plans had not been followed through, a similar finding by Robert Francis QC in the Mid Staffordshire Inquiry indicating failures of governance at Board level. At Inquest, again, there was a finding that Action Plans had not been followed through regarding the Trust's own Serious Untoward Incident (SUI) into our daughter's death. http://www.eoe.nhs.uk/news_archive.php?area_id=9&id=72 http://www.eoe.nhs.uk/news_archive.php?area_id=9&id=71 6. We made an official complaint in July 2008, this was answered in January 2009. This was not to our satisfaction as a number of questions remained unanswered but it stated it was final so we had to go to the next stage, which by the time we pursued this, was the Parliamentary Health Service Ombudsman (PHSO). 7. The SUI was made available to us in October 2008. Again, it was clear that Trust Policy was not followed in undertaking the investigation itself, no root cause analysis. Whilst there was recognition of the failure of the CPA and lack of a carer's assessment, there was no alignment of her care to a number of Trust Policies or National Guidelines. In fact, the deficiencies in this report were similar to those found following the Investigation into West London MHT. http://www.cqc.org.uk/_db/_documents/Investigation_into_West_London_Mental_Health_NHS_Trust_FINAL_200907171608.pdf 8. What it quite disturbing is that the Chief Executive of this Trust was part of the investigating team into West London NHS Mental Health Trust . However, he did not appear to recognise these deficiencies of which he was supposed to have been an expert. Freedom of Information appeared to show a review at Board level. No concerns were found! You do not have to be a trained Psychiatrist to appreciate the appalling care, or lack of care, provided so this would an unreasonable finding. We were told this review at board level was not documented. 9. We wrote to the Trust regarding our concerns of the SUI in November 2008. In May 2009, the Coroner's Expert Witness confirmed our findings of the poor and unsafe care. We received a reply to our letter regarding the SUI shortly after. The Clinical Director and Psychiatrist from the Trust were not in agreement with the Expert Witness. They were of the opinion that information regarding a patient's instability was not relevant when treating that patient!!!! We were now very, very concerned. This was not a safe Trust. In the three years between 2006 and 2009, there were 17 unexpected deaths or otherwise known as preventable deaths. If this was an Acute Trust rather then a Mental Health Trust, there would be a public outcry. There were indications that patients were not being adequately risk assessed and were being discharged prematurely into the community, as in our daughter's case. This was dangerous as Care Co-ordinators were working in excess of the Department of Health recommended 35 client limit. In fact, in 2007 the Trust had identified shortages in community staff but this had not addressed nor identified in the SUI. In April 2009, there was a homicide, at a time identified as unsafe by the Coroner. East of England SHA have confirmed that there will be an Independent Investigation under HSG(94)27 in 2011 into the care provided by SEPT to this patient. 10. We pursued our complaint to the PHSO late 2009. They were aware of the Coroner's Expert witness report but due to court protocol, were not allowed to take this into consideration. However, this should have been enough to alert that something was wrong and we emphasised our sincere concerns regarding patient safety. From our experience, communication was mainly done over the telephone with no follow up written correspondence to confirm what was said and actions to be taken. We did email eventually our concerns and that we had suffered hardship in that we were unable to use our local services as we knew it was unsafe and had to pay for private care. We also reiterated the inadequate Trust investigation with similarities to those found at West London MHT. However, the PHSO turned down our complaint. On obtaining Freedom of Information, they had wheeled out a so called "expert" who simply stated that the Trust had undertaken an investigation and had fulfilled its obligations. The fact that this investigation was inadequate was not explored, nor were the patient safety issues or our hardship. We have lost faith in this process. 11. We had also alerted the EOE SHA. Again, under a FOI, the monitoring of Action Plans following independent investigations under HSG(94)27 was merely obtaining updated Action Plans. However, Dr Paul Cosford did contact Barbara Stuttle of West Essex PCT to undertake an investigation. Following the Inquest, we did meet with Barbara. She apologised that they had taken SEPT at face value when their response should have been more robust. 12. We are now awaiting the terms of reference for a review regarding the implementation of the Rule 43. However, there will be no root cause analysis of why the system failings occurred so there is potential for areas of concern remaining. For example, why did the Care Co-ordinator have 37 clients? Why, after two years, did the Care Co-ordinator and others still not know what a crisis and contingency plan were? Why were letters from other professionals not copied to the Care Co-ordinator? How many other patients were receiving poor and unsafe care? There is also going to be a review of the SUIs whereby the PCT are already suspicious that the quality and fitness of these reports are questionable and that patients may have been harmed. 13. How did this Trust manage to get an "excellent" rating you may well ask? It is probably down to self promotion, manipulation of the ratings system and passing on false information to provide assurance. We have documentation to support this view. 14. It is also down to a failure of the monitoring bodies. These relationships appear too "cosy" where the concept of "good faith" is abused by this Trust. We have pointed out blatant lies to the Care Quality Commission, such as after the Inquest the Trust passed on assurance that our daughter's SUI was undertaken by Personnel trained in root cause analysis when this was not true. You would think we would be thanked but they don't seem to care and act as "apologists" for the Trust. 15. Our position is that we have followed the NHS complaints procedure. This has been a complete failure with the lack of an apology by the Trust and failure by the PHSO to undertake an investigation and a lack of a remedy despite our hardship. Our only option now is to take legal action. 16. Outside of the NHS complaints system, the Coronial system has, as a finding of fact, found SEPT to be an unsafe Trust. The SHA and PCT eventually recognised that there were serious concerns. But in the meantime, SEPT were allowed to empire build and allow this unsatisfactory culture and leadership, the pursuit of self promotion at the price of patient safety, to be enforced upon others. 17. We hope that it has become apparent that there is a serious lacunae in the NHS complaints system. The PHSO does not have patient safety as a main guiding principle. It does not have this as a principle at all! If we had not obtained the medical records, then these serious system failings would not have been identified as the Trust were either incompetent and did not recognise these failings or deliberately decided to ignore them. Any of these scenarios are indications of failings of governance at board level. If our daughter had the appropriate care, treatment and monitoring, she would be alive today. 18. Please take into account the vulnerability of patients and their families and the probable under reporting of poor and unsafe care.