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I’ve brought my children up on the principle that if you’ve done wrong, being willing to say sorry is a good start, but only a start.

In our house, there are two more necessary components to an apology. You have to say sorry specifically for what you did wrong, and in a way that helps the person to whom you are apologising feel better. And then you have to do sorry: think about how to avoid upsetting that person – and other people – in the same way in future and work on that prevention.

 It doesn’t just apply to the children.  When we offend, we adults have to apologise too, sincerely and without reservations; and then we have to do better afterwards.

Grenouille understands this.  Not saying the execution is always perfect – who enjoys admitting they are wrong? – but the effort is there.  G knows that no-one, not even a parent, is beyond reproach; and that you don’t need to be clever to say and do sorry.  Even a child with learning disabilities can figure out ways to make things better after they’ve set them awry.

Not, it appears, at Southern Health.  This is the best they could do after Nico Reed’s inquest.  Nico’s mother has written an hilarious politely-sarcastic reply, behind which her disbelief, her forced-upon-her cynicism and her absolute outrage stand screaming.

If I had had a say the upbringing of the person who should have written that letter (and no, I’m not old enough to be her mother, but am of an age to have been her big sister) it would have read something like:

Dear Mr and Mrs Reed,

My name is … and I am….

I am writing on behalf of Southern Health Trust, with the knowledge and endorsement of the Trust Board, to apologise to you from the Trust as a whole, for our part in the death of your son Nico.

We are sorry that during our takeover of Ridgeway, we didn’t do the due diligence work that could and should have shown up the holes in Nico’s care. We are sorry that because we didn’t do this work, poor practice was allowed to continue.  One aspect of this poor practice was that there were too few staff on duty overnight for the needs of the residents, so Nico was not cared for according to his Plan and as a consequence he died when he might have been saved.  We are sorry that we misled you over the timing and nature of Nico’s death.  We are sorry that we refused to talk to you and tried to hide the causes of Nico’s death from you.  We are sorry for claiming that needs specified in a care plan were guidelines, not requirements.  We acknowledge that we were trying to wriggle out of the liability that was properly ours, and we are ashamed of and sorry for that.  We are sorry for being too cowardly to face up to our responsibilities and for hiding behind taxpayer-funded lawyers in our attempts to evade responsibility.  We are sorry for causing you over two years (and counting) of additional grief and stress by our evasions.  Above all, we are sorry for Nico’s unnecessary death and for our failure to spot, and insist on, the changes that could have prevented it.

We are now ensuring that all care plans are rigorously specified with information from families and previous carers as well as our own medical staff, by <process>, and we are making sure those plans are fully adhered to from residents’ first day with us.  We have put in extra staff to provide the hours needed for each resident to get all of the care specified in his or her Plan.  Our system for checking that care plans are followed consists of <…..>
We have reviewed how staff communicate with families in emergency situations. All staff are now trained by <this appropriate, named organisation> in emergency communication and will receive refresher training annually.  We have tightened up how documentation is done by <process> and we have also put <these contingency arrangements> for cover staffing in place so that if ever there is an emergency, the staff-members involved will be enabled to record events immediately and fully.
We have put in place an airline-style no-fault near-miss reporting system and policy.  While staff are not sanctioned for concerns or mistakes that they report, they are liable to severe sanctions, in accordance with Section N of the policy, for failing to report near-misses that subsequently come to light.  Friends and families of patients are able and encouraged to make reports through the near-miss system by <…..>   So far, the near-miss reporting system has drawn to our attention <these> issues, which we have addressed by <actions>
If we take over or set up any other long-term care facilities in future, we will ensure that we check them against these standards and we will have our systems installed at the first opportunity.

We know that none of this can bring Nico back.  We hope that what we have done begins to reassure you that we are trying our hardest to make sure that what happened to Nico never happens to anyone else on our watch.  If you think we should be doing something more, or something differently, please get in touch with <name of top relevant manager> via <choice of communication channels> to flag it up.  We promise we will investigate your concerns fully and include you in the process according to your wishes.

Please let us know if you would like to hear from us again.   For example, we could arrange to let you have an annual report each year on our residential homes, or we could do something else that you would prefer, to let you know how we are maintaining and improving on the systems we have outlined above.  
If there is anything else we can do, at any time, to reassure you that Nico is not forgotten, and neither are the lessons that we should have learned straight away, you only have to tell us.  
You can contact us via <these various channels> or by using the enclosed SAE, whichever suits you best. 

I feel that as Chief Executive of the Trust, responsible for the overall organisation of our services, I also owe you a personal apology.  I am sorry for not preventing,  within the organisation that I lead, the failings that contributed to your son’s death.  I apologise for not ensuring that, after Nico died, events were managed to cause you as little additional stress as possible.  I’m sorry.   

Yours sincerely

Katrina Percy

Chief Executive

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