Health chief was told FIVE YEARS ago that patients were at risk but failed to follow advice… so why is she still in a £240k job?
- Katrina Percy ex chief executive of Southern Health NHS Foundation Trust
- Report accused Trust of not considering patient safety its ‘core business’
- Percy allegedly warned suicidal patients kept in rooms with ligature points
- Inspector claims she ignored warnings despite high hanging rates in Trust
Whistleblower Mike Holder has accused former NHS chief Katrina Percy (pictured) of ignoring health and safety warnings
Pressure was growing last night for an under-fire NHS boss to quit her £240,000-a-year job after fresh allegations her trust ignored warnings that could have saved lives.
A whistleblower says Katrina Percy failed to act after being told Southern Health NHS Foundation Trust was housing suicidal patients in rooms full of places they could hang themselves.
Health and safety consultant Mike Holder wrote in a damning report that the trust, responsible for 45,000 vulnerable people, did not consider patient safety part of its ‘core business’.
Mr Holder told The Mail on Sunday he emailed his dossier directly to Ms Percy, who was then the trust’s chief executive, nearly five years ago – but his warnings went unheeded.
Among his claims, Mr Holder alleges that Southern Health:
- Failed to remove ‘ligature points’ – where a noose could be attached to lethal affect – from rooms used by vulnerable patients;
- Did not investigate a five-fold surge in attempted hangings by patients in the five years prior to his report;
- Ignored him when he told them safety systems were ‘dysfunctional’ – a failing he feared would result in patients being able to kill themselves.
Mr Holder had been commissioned by the trust to investigate health and safety in 2011 but resigned after three months because he was so concerned by what he found.
He said: ‘I firmly believe people died unnecessarily because Southern Health, with Katrina Percy at the helm, failed to follow my advice.’
His views were backed by relatives of patients who hanged themselves in trust facilities using ligature points that should have been removed.
Roger Colvin, whose ‘beautiful and kind’ wife Teresa, 45, killed herself, said: ‘I am absolutely sure her death was preventable. She went there believing it was a place of safety, but they failed her.’
An internal review found ‘no evidence of negligence or incompetence of any individual board member’ at the trust and announced Ms Percy could keep her job.
But two weeks ago she stood down as chief executive of Southern Health, claiming ‘media attention’ was making it impossible to do her job.
However rather than give up her £240,000-a-year remuneration package, including her £190,000 salary, she moved sideways to a job created for her, giving strategic advice to GPs. She was the only applicant.
Calling on her to resign immediately, Mr Colvin, 64, a company director, said: ‘She was aware of risks to patients and did not take specific action – she should go.’
Last night, former health Minister Norman Lamb called on Southern to sack Ms Percy if she was ‘not humble enough’ to resign herself.
He said: ‘When there have been so many apparent failures, leaders have to take responsibility. You can’t simply shift sideways to a job, with that level of salary, which last week was not even deemed necessary.’
The Lib Dem MP said he thought the trust had ‘a fair basis for terminating employment’. Demanding the board ‘urgently reconvene’, he said: ‘They need to recognise it’s not sustainable to persist with this appointment.’
Conservative MP Sir Nicholas Soames agreed: ‘I think Miss Percy should have gone quite some time ago. The idea that this job should have been created especially for her is appalling, grotesque, and she must go now.’
He believed the situation at Southern Health revealed ‘a terrible failing of corporate leadership at the top of the health service’.
Southern Health last night told The Mail on Sunday ‘considerable improvements’ had been made since 2012, with more than £2 million spent making its buildings safer, but gave no indication Ms Percy would quit.
TRAGIC DEATH OF TERESA COLVIN AT SECURE HOSPITAL
Riding instructor Teresa Jane Colvin strangled herself using a telephone cord from a communal kiosk within 48 hours of being admitted to Woodhaven Hospital in Southampton.
The danger posed by the kiosk, which was out of the sight of staff, had been officially noted in 2009 – three years earlier. But nothing was done.
Her devastated widower Roger Colvin said: ‘After the event, I was staggered to find the cord – which had been so long you could do your washing on it – had been shortened.’
So had cords at Southern’s other secure units. ‘They could have done that before Teresa died,’ said Mr Colvin. ‘It wouldn’t have been expensive.’
Southern admitted liability for 45-year-old Mrs Colvin’s death.
Last night Mr Colvin told The Mail on Sunday he was ‘astounded’ to hear Southern had been explicitly warned of ligature point risks in 2011.
He said: ‘For management to ignore these risks, pointed out by their own health and safety expert, is unacceptable.’
Mrs Colvin suffered bouts of Post Traumatic Stress Disorder after suffering abuse as a child but they only tended to last a few days, said her husband. She was often ‘very well’, putting huge energy into her horses and beloved labradors.
He said: ‘She was a beautiful woman, I loved her dearly. And now she is gone.’
The trust first hit headlines last December when a report commissioned by NHS England concluded it had failed to investigate 450 ‘unexpected’ deaths between April 2011 and March 2015.
That report only took place because a grieving mother, Dr Sara Ryan, asked why her epileptic son Connor Sparrowhawk, 18, had been left alone in a bath at one of Southern’s units in 2013.He had a seizure and drowned.
It took three years for the trust to accept responsibility for his death.
But Mr Holder’s report, in February 2012, reveals bosses were warned about an apparent cavalier attitude to patient safety long before Connor died.
Mr Holder compiled the report a week after resigning, three months into a six month contract as interim head of health and safety.
In his resignation letter to Ms Percy, he said he was not supported by the trust’s board, and believed patient safety was way down its agenda.
Rather than deal with his resignation personally, Ms Percy handed it on.
Dr Huw Stone, medical director at the time, asked Mr Holder to spell out his ‘serious concerns’ in more detail. Mr Holder thus compiled a 13-page report supported by numerous email exchanges with staff.
In it, Mr Holder concluded: ‘It is my professional opinion that health and safety is considered an adjunct to the trust’s core business rather [than] an integral element of it… health and safety is not considered as an essential element of the trust’s undertaking.’
He told Southern Health such an attitude – in an NHS trust responsible for society’s most vulnerable and unstable – manifested itself in poor safety checks and record keeping of incidents where people came to harm.
Mr Holder said: ‘I essentially warned them: “Your safety systems are dysfunctional and because of this patients will succeed in killing themselves”. But they didn’t listen.’
In particular, he identified a dramatic increase in patients trying to hang themselves in Southern’s secure units over the previous five years. He discovered little action had been taken to eliminate potentially lethal ligature points, such as door handles, lights, beams and pipes, he said.
He recalled: ‘What I found was really quite shocking.
‘Ligature incidents’ had risen five-fold between 2007 and 2011, from 76 to 407, he discovered, adding: ‘Nobody had ever done this [research] work before, or if they had, there was no evidence of it.’
Southern’s way of assessing potential ligature points across its estate was also inadequate, he found, so he started a review.
In early February 2012, he put his findings to a senior manager, who suggested the trust had to ‘tolerate a certain degree of risk’.
Furious, Mr Holder emailed back a warning that under law Southern had ‘an absolute duty to ensure the safety of its patients, particularly those that are vulnerable’.
Powys Local Health Board in Wales had been fined £30,000 and ordered to pay £46,850 costs after a suicide, because the NHS body had ‘failed to provide a safe environment for a vulnerable patient’, he told them.
Two weeks later, frustrated at the lack of action, he resigned.
Mr Holder, an experienced chartered safety practitioner who has worked for construction firms and a commercial diving operation, said: ‘I thought “This is going to end badly for me. If something bad happens, they will use me as a scapegoat”.’
In his report, he further wrote that management erroneously believed ‘that ligatures are being managed effectively’, despite a ‘consecutive and significant increase in [ligature] events over the last five years’.
His report also identified ligature points in patients’ rooms at Ravenswood, a secure unit outside Fareham, Hants, and concluded the trust was breaching multiple health and safety laws.
Two months after his report, Teresa Colvin killed herself using a telephone cord ‘as long as a washing line’ at Southampton’s Woodhaven Hospital.
And in August 2014, biochemistry graduate James Younghusband, 30, hanged himself in his Ravenswood room from a downpipe that should have been removed.
The following February – three full years after Mr Holder’s warnings – the Care Quality Commission concluded Ravenswood was ‘unfit for use’ because ligature points posed a danger to suicidal patients.
Katrina Percy blandly responded: ‘We know that there will always be things we can learn from and ways we can make our services better.’
That was not all. This April, the CQC ordered Southern to make ‘urgent improvements’ to protect patients ‘at risk of harm’, concluding ‘it did not adequately ensure it learned from incidents to reduce future risks to patients’.
Percy, battling to stay in post after the 2015 unexpected death report, claimed ‘good progress’ had been made, adding: ‘My main priority is, and has always been, the safety of our patients.’
But Mr Holder said: ‘What I saw at the trust was like The Apprentice, except no one was told, “You’re fired,” however many deaths there were.’
He added: ‘In any other organisation, the board would force her to resign. I’m absolutely amazed that she has not been held to account.’
The Mail on Sunday approached Ms Percy at her £500,000 five-bedroom Hampshire home yesterday, but she said: ‘I am not giving interviews. Please talk to the trust.’
A spokesman for Southern Health NHS Foundation Trust said: ‘We express again our sincere apologies and condolences to the family and friends of James Younghusband and Teresa Colvin.
‘We fully accept they were failed by the trust and we are working extremely hard to ensure we never let this happen again.
‘The safety of people using our services is of utmost importance. Mike Holder’s report was reviewed in 2012 and considerable improvements have been made since.
‘Reducing risks associated with ligatures is a top priority. We have spent over £2 million to remove or minimise the risks of ligature points.
This includes a major renovation of Ravenswood House. We have appointed a dedicated ‘ligature manager’ and provided additional training and support to staff.’
- The Samaritans can be called free, at any time, on 116 123.
And who reported the Teresa Colvin case to the Health & Safety Executive? Not Southern Health, not the Coroner and not the CQC. I spoke to the Regional Director of the Health & Safety Executive and sent him a newspaper cutting – it was the first he had heard of it. The BBC report that the HSE is now carrying out a criminal investigation.
I will make it my business today to check that the HSE knows of the Younghusband case too.
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