‘Good’ rating for NHS trust once shamed for patient deaths

Southern Health NHS Foundation Trust
Dr Nick Broughton, chief executive of Southern Health NHS Foundation Trust

A LOCAL NHS trust that has battled for years to turn itself around after being publicly shamed for the deaths of patients in its care has been awarded a ‘good’ rating by inspectors.


Southern Health NHS Foundation Trust has seen bosses come and go, Whitehall intervention, and been hauled before the courts since a series of fatalities were exposed in 2015 with the help of campaigning relatives.

Its previous overall rating of ‘requires improvement’ has now been upgraded by the Care Quality Commission to ‘good’– the second best of four.

The trust is based at Tatchbury Mount, near Totton, and provides mental health services in Hampshire. It employs more than 5,900 staff, and is responsible for hospitals at Lymington, Hythe and Fordingbridge.

The improved CQC rating comes after a visit by inspectors in October last year to check acute wards and intensive care units for children and adults, and whether the trust was now well led after years of failure.

As reported in the A&T, in 2016 its chief executive Katrina Percy resigned and in 2018 it was fined £2m in a Health and Safety Executive prosecution, including the case of Emery Down woman Teresa Colvin who died at the former Woodhaven unit from a ligature incident.

Teresa Colvin died at the Woodhaven unit at Tatchbury Mount, Calmore, in 2012

One of the notable findings by the CQC was that “significant work” had been done to minimise ligature risks, including to fittings such as curtains and door censors.

Dr Kevin Cleary, the CQC’s deputy chief inspector of hospitals, praised the trust, saying: “Patients’ needs came first, and staff worked hard to deliver the best possible care with compassion and respect.

“The trust did face some challenges and there are still some areas of improvement required but there has been a significant improvement in the services at this trust. Staff, patients and the leadership team should be proud of the work done so far.”

In the sub-category of “being effective” the trust was rated as ‘requires improvement’.

However, it was ‘good’ for being safe, caring, responsive to people’s needs and well led. Over 90% of services were rated as either ‘good’ or ‘outstanding’.

The CQC said the board had improved the trust’s culture and morale, and senior staff members had worked closely with families who had previously suffered poor experiences.

Staff caseloads were not too high to give proper attention to patients, and those who needed urgent treatment were seen promptly.

Some improvement required by the last inspection had not been made, however, including making sure that female-designated lounges were not used by males, that patients could make phone calls in private, or that all staff understood their responsibilities under the Mental Capacity Act.

Trust chief executive Dr Nick Broughton said: “I am very encouraged by the report published today.  It reflects the significant strides we have made to improve the quality and safety of all services.

“It also highlights how hard we have worked to ensure we better involve families and carers in the care of our patients and service users.”

The report was a step towards reaching “outstanding” status, he said, and to provide “world class services”.



  1. I met with the CQC inspector for Hampshire,just before this inspection and informed them about poor leadership,poor service and other serious failures which in my opinion are continuing to put lives at risk.Clearly this warning fell on deaf ears.The CQC being part of the NHS system,clearly are no unbiased in their inspection / evaluation of other NHS services (especially mental health /learning disabilities),they tend to take a tougher approach towards the private sector which may be deemed unfair or even unlawful .Sadly patients are still being failed by SHFT and other NHS mental health services across the country ,because they refuse to acknowledge their failings in their behaviours / practices.They (SHFT) just rebrand the same practices and repeat the same behaviours over and over again ,even though they know do not work or even harm patients ,but they expect a different outcome.That to me is the definition of of insanity.It could be perceived that the CQC are failing in their duty of care in so far as they are failing to ensure the care needs of the most vulnerable people in hampshire are being met.In my opinion SHFT have not improved to the level that the CQC would have you believe and I would take there report with a bucket of salt !.I would suggest to any of your readers ,if they are in need of mental health care / treatment,that they go to their GP and ask to be referred to a private consultant via the clinical commissioning group (CCG).Stating clinical exceptionality, on the grounds the NHS do not provide the services you require.I believe NHS mental health services should by law have a disclaimer on entering any of there services “ENTER AT YOUR OWN RISK”.

  2. I agree with the previous comment. I am deeply concerned for the safety of patients being ‘treated’ by Southern Health and about the competence of the Care Quality Commission (“CQC”).

    I met the CQC’s Head of Inspection, Mental Health and Community Services (“MH/CS”) South and a local inspector during this inspection: I provided proof of continuing failings at Southern Health, which I also sent direct to its new Deputy Chief Inspector, MH/CS. A bereaved father provided a highly critical report too, which I have seen.

    Having campaigned (with service users, bereaved families and the media) for change since 2016, I am devasted that the CQC and Southern Health appear to have learnt nothing from the past. Fellow campaigners feel the same.

    It is clear too that the CQC did not consider the findings of 2018/19 Inquests, which exposed continuing lack of learning and serious shortcomings at Southern Health, including failure to report the alleged rape of a deceased patient to the police, withholding a key document from the Coroner, and contaminating the scene of death.

    How can a Trust be rated good when it acts in this way and when, for example, its Chair has to apologise in writing to a mental health patient and his adviser for intimidatory conduct, which led to the patient fleeing a meeting (held in public) without asking a question he intended to pose?

    As for the CQC stating that senior Trust staff members had worked closely with families who had previously suffered poor experiences, at least three of these families vigorously refute this claim.

    However, the CQC’s report on Southern Health should be read in the context of other inspection reports and the 2nd Report (2019 session) of the Joint Parliamentary Committee on Human Rights (“JCHR”), which heavily criticised CQC inspections. The JCHR concluded of the CQC:

    “A regulator which gets it wrong is worse than no regulator at all.”

    Other key findings by the JCHR include:

    1. The CQC, as regulator, should be a, “Bulwark” against human rights abuses of those detained in mental health hospitals. Its ability to protect patients against human rights abuses is, “Impaired” and, “Urgent reform” of its approach and processes is, “Essential”.

    2. Concerns raised by patients and family members about treatment must be recognised by the CQC as constituting evidence and acted upon.

    3. A review of the system which currently allows a service to be rated as, ‘Good’ overall even when individual aspects, such as safety, may have a lower rating.

    The JCHR’s inquiry was triggered in May 2019 when BBC Panorama exposed serious abuse and mistreatment of vulnerable adults at Whorlton Hall. The CQC’s then-deputy chief inspector of MH/CS, told Panorama: “On this occasion it is quite clear that we did not pick up the abuse that was happening.”

    Health Service Journal analysis also showed that, after the Whorlton Hall scandal, the CQC down-graded six mental health hospitals to, “Inadequate”, just months after describing them as either, “Good” or, “Outstanding”!

    The CQC also rated Norfolk and Suffolk Foundation Trust, “Requires improvement” for whether services were safe, responsive, effective and well-led and, “Good” for whether services were caring. But Healthwatch Suffolk said there was, “A disparity between what the trust reports, the outcome of this inspection and the experiences of service users and carers”. The local service users’ champion said it had noticed, “Very little improvement in peoples’ recorded feedback”.

    The evidence suggests that these criticisms can be levelled at the CQC’s latest inspection report of Southern Health, despite the appointment of a new Deputy Chief Inspector MH/CS.

    As recently as 21 January 2020, ‘The Times’ reported that, during an audit, the CQC found, “Duplicate material” in 78 reports, with identical quotations from patients or sections of evidence pasted into reports on different institutions. As a result, the CQC has decided to carry out several re-inspections.

    In all the circumstances, I agree that the CQC report on Southern Heath (which, in my opinion, deflects the truth) should be treated with a huge bucket of salt.

  3. To update the sixth paragraph of my previous comment, I know now that all five of the families vigorously refute this claim. Also, another campaigner (and ex-governor of Southern Health) has posed the rhetorical question –

    “Remember the CQC never picked up on unexpected deaths exposed by Mazars. Why is anybody taking notice of it [now]?”

    This is a matter of record.

  4. UPDATE : Since my last comment Dr Nick broughton, as reported in the oxford echo has left southern health foundation trust. He will now be the chief executive at a health trust in oxford ironically didn’t SHFT have to give up providing services for learning disabilities in oxford ? .The news comes just as SHFT have allegedly improved .Via the CQC gifting them a rating from ‘requires improvement’ to ‘good’ . In my previous comment I have stated that I would not trust the CQC rating at all .Sadly it just comes across as if Dr broughton is jumping a sinking ship and leaving the job unfinished,that’s if you believe that SHFT have indeed reformed their ways which his exit would cast doubt on that ‘good’ rating from the CQC.Since 2016 SHFT have had two permanent and one interim chief executive.Also they have gone through three or four chairpersons in that time also.It comes as no surprise to me he that has left after such a relatively short time in post as NHS trusts ,especially SHFT seem to be used as a stop gap or even a springboard into other positions for executive board members.The one comment in the oxford echo ,which comes across like a SHFT employee says “maybe he (Dr nick broughton) would like to take the medical director with him”.If this is a SHFT employee it gives the insight that maybe all is not as rosy as the CQC would have us all believe.

  5. Russell if you are going to quote me from my post in the OM could you please quote it in full and not cherry pick


  6. The Pascoe Report into Southern Health was issued today in a cack-handed manner typical of NHSI. It was issued without an embargo notice but recalled soon afterwards, therby causing yet more distress to those involved. It vindicates my previous comments here but, in fairness until the report is reissued, I will just report the fact that a Public Investigation into Southern Health is recommended. So much for the CQC’s inspection report!

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