Saturday, 28 February 2015

The Museum of Nothing in Particular Part 4; My Cupholder Vitrine


A couple of years ago I was writing about ‘vitrines’ where an artist tells a story using a small glass case filled with small, intimate objects. I thought I’d do one myself and I decided to post it again in my 'Museum of nothing in Particular' series.

I cleared out the 'rubbish' from the cupholder in my car and here are the random objects I found there.
Bottom left is a spatter of tin solder that I found on the ground after some work was done at my last ever workplace.

Just above that is a small quartz pebble I picked up on holiday on the North York Moors in 2010.

On the right of the pebble is a shell I picked up on a day out on the south coast near Newhaven in 2011.

At the top is a bit of a mystery. I picked it up on a pavement in Staines – it’s made of plastic resin. I think it’s a by-product of a manufacturing process, rather like artists or painters scrape the paint off their brushes when they clean them. Over the years they build up the residue into a solid coloured block. I’m guessing this came from making objects out of fibreglass resin, but I could be wrong.

There you have it, some snapshots of my life over the last couple of years before I got ill.

Neil Harris

(a don’t stop till you drop production)

Friday, 27 February 2015

Feeling waspish.

Spring is definitely busting out even if I'm not; I went out to pay my credit card bill.

I'm late - I couldn't pick up my mail until I could drive. Well, I've been driving despite a couple of cracked ribs, but only to take my partner to the bus and back. I've been leaving a stream of swear words trailing behind the car.

Today I drove to Barclays bank which recently did away with people, replacing them with machines.

Unfortunately, their sparkly new machines can't do the transaction I need done. Usually, they let me use the 'International and Commercial banking counter' (very grand) because there is still a human being there.


His machine was broken and I couldn't do it. I had to drive to the next town, groaning all the way.

It hurt at very corner, every gear change.

I need to change credit cards, because if I hadn't been able to do this today I would have been fined, charged interest and had my credit history messed up.

These crocuses came up weeks ago but they haven't opened their flowers much; they've been waiting for the sun to shine.

It's been beautiful today.

Neil Harris
(a don't stop till you drop production)


Contact me:

Thursday, 26 February 2015


Another selfie!

Actually this is pretty much how I look at the moment. After three months of Broncitis and a really bad back, last week I cracked a couple of ribs.

I'm not sure what exactly what I did to myself but I did it once before and it didn't hurt as much so I'm guessing that I broke something.

I have been working my way through my collection of swear words for the last week.

I then went and did something terrible to my back as well.

You really don't want to me.

Anyway, as a result, I've been posting articles about St. Peter's which is what this Blog was supposed to be all about.

I'm beginning to come out of the agony now and I'm hoping to get back fighting again soon.

All I can say is that I wouldn't recommend cracking a rib or two - there are better things to do.

Neil Harris

(a don't stop till you drop production)


Contact me:

Wednesday, 25 February 2015

Deaths at the Abraham Cowley Unit at St. Peter's Hospital, Chertsey.

Ashford and St. Peter’s NHS Foundation Trust takes up a lot of my time; you wouldn’t think I’d want to take on any more. You would be right.

However there is another scandal in the grounds of St. Peter’s Hospital, Chertsey although it doesn’t involve the Trust.

The Abraham Cowley Unit is a complex run by ‘The Surrey and Borders Partnership NHS Foundation Trust’ which treats mentally ill people including those detained for their own safety under the Mental Health Acts. Patients there are normal people suffering from illnesses that require monitoring and management. Some of them need to be held in a secure environment for a time.

Most patients live normal lives but may need to stay as inpatients every so often. At those times, the hospital should be caring for them and providing them with a place of safety until they are well enough to leave.

No one wants a return to the days when such places were frightening gothic prisons and yet; a place of safety needs to be safe.

The Abraham Cowley Unit is not safe.

I visited the Unit a number of times in the 2000’s, visiting clients (when I was working). I also visited many other similar units and was often surprised by how poor the supervision and security was.

These inquest reports confirm that the Unit has been failing for a number of years.

The recent inquest of Simon Tree has resulted in The Coroner issuing a legally binding notice under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. Notices like this are made to trusts where unsafe practices have resulted in a death and where a Coroner has identified unsafe practices which are like to result in further similar deaths, if nothing is done. It requires the Trust to respond to the Coroner about how it intends to avoid similar deaths in future.

The evidence given by staff is not what it should be;


Paranoid schizophrenic Simon Tree had threatened to jump in river two days before death, inquest hears;


 Get Surrey   

 23 January 2015 

 By Matt Strudwick


A coroner said he would be issuing a prevention of future death report to a mental health unit after four subsequent patients also absconded.


Simon Tree went missing from a mental health unit before drowning in the River Thames.


A man with paranoid schizophrenia threatened to "jump into a river" just two days before his body was found in the Thames, an inquest has heard. Simon Tree, 49 - formerly known as Gary Randall - was found dead by a canoeist near homes at Sunbury Court Island on February 18 2012.


A five-day inquest held at the coroner’s court in Woking this week was told Mr Tree was having treatment in the Abraham Cowley Unit (ACU), based at St Peter’s Hospital in Chertsey.


He was there voluntarily after setting fire to his Stanwell home in a failed suicide attempt a month earlier.


Mr Tree, who was diagnosed with depression at the age of 18, had been taken back to the unit by police on the evening of February 16, after he was found drunk and walking towards the river by a couple in Thames Street, Sunbury.


He had been reported missing by the ACU at 4.38pm.

PC Claire Phillips told the inquest how, when she and two colleagues returned him to the Blake Ward at the ACU, she felt charge nurse Stephen Livesley had not taken the situation seriously enough.


“I stated Simon said he wanted to jump into the river and, I wouldn’t say he was dismissive, but he said ‘they always say that when they’re drunk, it’ll be different in the morning’,” she said.


“I didn’t challenge the comment, but was surprised because he was so blasé about it.”


'High risk'


Mr Livesley said he had no recollection of the conversation, but had told colleagues Mr Tree should be reassessed the next morning by doctors when he had sobered up.


“It was the first I heard in terms of Simon wanting to put himself into a river,” he told the inquest. “First I knew Simon had any attempt to take his own life or may have had.”


The inquest heard Mr Tree was allowed off the ward by nurse Steven Hope at 8.20am the following morning, onto the main corridor for breakfast, where patients could gain access to the delivery area.


Mr Livesley said the area was used as the main entrance at the time, due to maintenance work at the front entrance, and the door was "insecure" and had "occasionally not closed fully".

At around midday, staff nurse Cecil Nhlangano raised the alarm that Mr Tree was missing after colleagues could not find him in the facility for an assessment.


It took staff until 7.40pm to report him missing to the police as they had thought he may have gone shopping.


“I disclosed with the ward manager, also, to try to come up with a plan,” said Mr Nhlangano.“What we concluded was to give him a chance to come back as he might have gone shopping.


“Those were some of the reasons as he had requested to do some shopping for clothes [earlier in the week].”


Coroner Simon Wickens asked why the "intervening event" [of Mr Tree being found drunk near the river] had not come into the discussions.


“You knew this issue where he was going to take his own life and you knew he had gone missing from the ward,” he said.

“At midday, is he not, in your mind, a high risk, given those events?”

But Mr Nhlangano said the risk had been minimised due to his return to the ward and him no longer being intoxicated.


Mr Tree was not found until 5pm the following day, when firefighters pulled his body out of the river.


His father, William Randall, said; “At Christmas 2011, he said he felt like jumping off Staines Bridge but had shuddered at the thought of it. “The last time I saw, Simon was on Blake Ward on February 15, when I brought him in some more socks.”


A post-mortem examination concluded he had died from drowning, with toxicology results showing small traces of prescribed drugs Citalopram and Risperidone, which were being used to treat his depression and schizophrenia.


Giving a narrative verdict on Friday morning, Mr Wickens said he would be issuing a prevention of future death report to the unit after four subsequent patients absconded in the past year - "four too many", as he described it.


"In one incident the camera covering the air lock was moved to a blind spot to assist a patient to leave," he said.


"I propose to make a prevention of death report to the unit to take steps to address those issues and closer monitoring of those exiting the building."

I’m not surprised that the Coroner was angry about the four recent absconders from the Unit but the situation was worse than that.

This next report is again from ‘Get Surrey’ and it concerns another recent inquest which also deals with a death from 2012 (why does it take so long?).

This is negligence plain and simple. There was no assessment of her mental state on her return to hospital and how on earth did she get hold of a knife in a place of safety?;


Mental health unit failings contributed to Katherine Bonaventura death, inquest jury decides.


Get Surrey.

14 January 2015 

By Becca Taylor


The 28-year-old, who was a diagnosed schizophrenic, stabbed herself in the chest but an inquest jury said there was not enough evidence to establish if she had intended to cause her death. Failings in procedure at a mental health unit in Chertsey "more than minimally" contributed to the death of a promising musician from Godalming, an inquest jury has ruled.


Katherine Bonaventura, who lived in Warramill Road, died in December 2012 from a haemorrhage after a stab wound to the chest, sustained while she was a detained patient in the Abraham Cowley unit based at St Peter's Hospital.


Miss Bonaventura had returned to the unit following overnight leave with her mother Patricia on December 7 2012.


She returned just after 11am and her registered clinician Dr Sheetal Sirohi had plans to see her for an assessment at around 2pm that same day.


Miss Bonaventura was found in a corridor at the unit shortly after 2pm, with a knife in her chest.


Paramedics attended and she was transferred to the trauma unit at St Peter’s, but was pronounced dead at 4.22pm. She was 28-years-old.


A jury at the inquest ruled she died as a result of her own actions, but that there was not enough evidence to establish whether she had intended to cause her death.


The jury also ruled that the unit had failed to elicit information when Miss Bonaventura returned that day, and that they failed to "sufficiently and immediately" assess her mental state.


'I'm going to hell'


Miss Bonaventura was diagnosed with schizophrenia in 2009, and over the following four years had various periods in hospital, both voluntarily and under section three of the Mental Health Act.


The night before her death, Miss Bonaventura had been celebrating her mother’s birthday at a restaurant with friends.


Mrs Bonaventura said she had tried to express concerns to staff at the ward when they returned that her daughter had been drinking heavily, which was at odds with the anti-psychotic medication she was on, but that she felt the concerns were dismissed.


Giving his evidence, Sunil Boo Jharut, charge nurse at the unit, said he had no recollection of Mrs Bonaventura expressing any concerns about the leave, and that no formal note had been made of any handover.


After the alarm was raised, Dr Sirohi cradled Miss Bonaventura as she lost consciousness.


Her last words were "I’m so sorry. I’m going to hell. Let me go".


Staff said Miss Bonaventura’s presentation seemed to be improving, though her mother said that just two days before she was granted the overnight leave there had been concerns she was having suicidal thoughts.


'Sad incident'


Assistant coroner Alison Hewitt confirmed that she had it in mind to write a report, or a letter, to the Surrey and Borders Partnership NHS Foundation Trust (SABP), which runs the Abraham Cowley unit, to make her suggestions as to improvements that could be made following the jury’s verdict.


Jo Young, director of quality at SABP, said: “We extend our heartfelt and sincere condolences to Miss Bonaventura’s family for their sad loss.


“Maintaining the safety of people who use our services is a vital part of our work, and across the organisation we are embedding all that we’ve learnt from this sad incident.


“Recommendations were made as a result of our internal review and these are being fulfilled to ensure we improve our practices.


"These have included clearer guidance for staff in relation to searching a person, their rooms and personal belongings, more detailed risk management plans, staff documenting feedback from carers, family, friends when a person returns from leave, and managing any identified risks appropriately.”

I’m very concerned that for the second time staff had no recollection of what happened and there appear to be no written records of what happened.

It’s a shame that a different coroner was dealing with this inquest; a combined report would have been better.

This next article (also from ‘Get Surrey’) last year was meant to be reassuring but it isn’t. It was written after the two deaths in 2012 but before the inquest’s this year.

You would think there were no problems;


Security levels improving at the Abraham Cowley Unit

Get Surrey

3 May 2014 

By Russell Butt


The director of mental health services at the Surrey and Borders Partnership NHS Foundation Trust has said the numbers of patients wandering off at the ACU has steadily reduced.


Security levels at a mental health unit in Chertsey are said to be improving, despite two worrying incidents in April.

The Abraham Cowley Unit (ACU), based in the grounds of St Peter's Hospital, has had issues in the past with patients going missing, although most return unharmed.

In one recent incident a patient was talked down from a bridge over the M25 in Green Lane, Chertsey, by a passer-by. Just two days later, another patient was coaxed down from a roof of in the hospital grounds, prompting concerns over security at the unit.


However, Andy Erskine, director of mental health services at the Surrey and Borders Partnership NHS Foundation Trust, which runs the ACU, said that despite these two incidents, the numbers of patients wandering off had steadily reduced during the past three years, even though more people were using the service.


He said: "With four wards for people with acute mental ill-health, the Abraham Cowley Unit in Chertsey is our largest in-patient site in the county.


"Our first priority is to keep people safe while they are with us and we are continually reviewing and improving the way we work.


"The number of people going AWOL (absent without leave) across our inpatient services, and especially at the ACU, has dropped significantly in recent years.

In 2009-10 the number of AWOLs from the ACU was 80, in 2011-12 it was 48 and in 2012-13 it was 10."


Mr Erskine said the overall AWOL figure for the trust as a whole was 43 for 2012-13.


He added: "This is a real success considering that more people than ever are staying at the ACU since a new ward opened in 2012. This reflects a concerted effort from us to improve security levels.


"We have invested in improvements such as secure card entry doors, as well as giving patients more opportunities to talk about their feelings so people understand why they should remain in our care.


"Some people are able to leave to see family or friends as part of their recovery and if they are late returning, then this has to be logged as an AWOL.

We would not expect a zero rate of AWOLs, although we are, of course, determined to keep this to a minimum to protect patient safety as much as possible.


"This means that if people are AWOL, we review what happened and try to improve our services."

The problem? We know from the Coroner that as of this year it is still a problem and in 2014 there were two very serious incidents that resulted in this rather complacent interview.

More worrying is that the Trust seems to think that 2012 (with only 10 absconders) was a good year; one of them died.

I’ll be watching Abraham Cowley closely from now on to see how many more incidents happen!

Neil Harris

(a don’t stop till you drop production)

Tuesday, 24 February 2015

Merger on hold; patients first or second?

You know how it is; you’ve sent out all the wedding invitations, you’ve booked a horse and carriage, there are geese at the front door, you've been given a lot of nice presents, all your family and friends are assembled in the church to watch you get married in a silly suit….and then the vicar asks if anyone has any objections to the marriage.
No one noticed the ex-girlfriend who just burst in through the door;

This time last year Ashford and St. Peters announced its proposed merger with The Royal County Hospital, Guildford.

It’s a merger no one wants – as I reported before; a survey of consultants at Guildford showed that over 70% felt there would be no advantage for patients.

Obviously there won’t be – mergers just don’t work. All the scientific research shows that hospital mergers result in poorer outcomes and increased management costs….whatever they say.

The proposed merger is all about closing departments, laying off workers and ultimately selling off precious land to balance the books.

Now, embarrassingly, the Competition Authority has put the whole process on hold to investigate whether this will actually work in the interests of patients;

Royal Surrey and Ashford & St Peter's hospital merger delayed for more assessment - Get Surrey 

Plans to merge two Surrey hospital trusts have been delayed after the Competition and Markets Authority (CMA) decided to carry out further investigations.


The Royal Surrey County Hospital NHS Foundation Trust, in Guildford, and Ashford and St Peter's Hospitals NHS Foundation Trust were hoping to receive the go-ahead to merge on Thursday (February 19).


However, the CMA has decided to refer the merger to a second assessment phase, which will take six months to examine the plans.


It comes after the authority said it had "found that the merger could result in adverse effects for patients by reducing choice and competition across a range of elective specialties".


Nick Moberly, chief executive at the Royal Surrey, said: “We’re obviously disappointed with this decision as we believe a merger would result in a number of positive benefits for patients."


Management boards at both hospitals were set to discuss the latest turn of events at meetings next week.


Ashford and St Peter's chief executive, Suzanne Rankin, added: "Although this was not the decision we were hoping for, we understand that the CMA needs to carry out a more in-depth analysis of our plans to ensure this is in the best interests of patients.

"Unfortunately this means we will need to wait longer until a final decision is reached.”


The trusts hope the merger will save an estimated £10m-£20m and have said patients will not notice any changes in services in at the three hospital sites.


However, staff expressed their concerns about the plans in a questionnaire seen by the Surrey Advertiser.


Results showed 72% of consultant staff at the Royal Surrey did not believe care for patients would be improved in the proposed partnership, while 74% said they did not think the merger would benefit their department.


Andrea Coscelli, executive director for markets and mergers at the CMA, said: “Our job is to look at the evidence and examine the impact that a proposed merger could have on patient choice and the quality of healthcare services provided.


"Tens of thousands of patients a year are treated by the trusts in the specialties we've looked at and could be potentially affected by the loss of choice they currently have.


"If the trusts no longer have to attract patients who might choose to go elsewhere, it could mean their incentive to maintain and improve quality in those specialties is reduced.


"We acknowledge that there may be some benefits which result from the merger but given the extent of our concerns and the number of specialties and patients involved, we feel it is necessary to look at this merger in greater depth to ensure that it is in patients’ interests."

If you want to know more about the destructive effect of mergers over the last 30 years have a look at my ‘Merger Mania’ pages.

Neil Harris

(a don’t stop till you drop production)

Monday, 23 February 2015

Patients; the last to hear about problems.

Ashford and St. peter’s NHS Foundation Trust has a number of problem areas but it’s PR department isn’t one of them. There’s a constant stream of good news stories for the local press.

Bad news? They don’t talk about that if they can help it.

So while you can read this story in “Runcorn and Widness World”, you won’t hear much about it around here.

The news is that Whiston hospital’s Cancer department is going to mentor cancer services at Ashford and St. Peter’s under the ‘buddy’ system.

It’s a great idea; where a hospital does something well they lend their staff to help a trust that isn’t doing very well to help it get its act together.

It means that the poorer hospitals learn best practise from the best.

How could I object to that?

I don’t.

My gripe is that the ill advised merger with Guildford’s Royal County Hospital is meant to allow Ashford to extend its cancer services to attract new business (yes – trusts now "compete" with each other so they need to woo business from other hospitals).

The problem is that cancer patients were the last to hear that there was anything wrong.

Let’s hope the buddy system works;


Runcorn and Widnes World

Whiston Hospital to 'buddy' another hospital to help improve the care of cancer


First published Friday 13 February 2015  in News  


A PIONEERING buddy scheme is set to improve the care of cancer patients in



Whiston and St Helens hospitals have been chosen to help share their positive

experiences with another hospital in Surrey.


St Helens and Knowsley Teaching Hospitals NHS Trust was identified by the cancer patient experience survey as being one of the most highly rated by patients.


It will be mentoring Ashford and St. Peter's Hospitals NHS Foundation Trust in

Surrey to help them improve their patients’ experience of care.


Ann Marr, chief executive of St Helens and Knowsley NHS Trust , said: “We’re really pleased to be part of this important project.


“We have a lot of respect for our buddy trust for taking part in the scheme too.


“It shows a real commitment to improving patients’ experience of care to take


“We’re looking forward to sharing some of the work we’ve done at Whiston and St Helens hospitals and supporting them to try out new ways of working.

“I’m sure both sides will learn a lot from this experience.”

The buddy scheme is being run by NHS Improving Quality, the national NHS

improvement organisation.

The aim of the scheme is to spread and accelerate innovative practice via peer

to peer support and learning.

Neil Harris

(a don’t stop till you drop production)


Sunday, 22 February 2015

A missed Sepsis; a lost life at St. Peter's Hospital, Chertsey.

It is so very depressing; I started this Blog two years ago because when I was taken by ambulance to the Accident and Emergency department at St. Peter’s Hospital, Chertsey I was unlucky; the consultant on duty was incompetent and I was sent home with a displaced, fractured ankle for a week.

I wanted to prevent more serious things happening to other people – there was clearly something desperately wrong with the A and E. if they couldn't spot an obviously broken ankle - what else were they missing?

My experience of the complaints procedure told me that nothing was going to be done.

But I’ve got cancer – there are other things I need to be doing and at times I’ve was diverted from this or I was just too ill to campaign enough.

I should have done more.

This story from yesterday’s “Your Local Guardian” deals with an unnecessary death in 2012 which occurred just 8 months before I was messed about.

Why has it taken so long? part of the problem is that we never actually hear what is going wrong until it's far too late.

Was it the same person who messed me up?

It’s time for that public enquiry I’ve been demanding;

From Your Local Guardian


Fight for life damaged by Ashford and St Peter's failure to spot sepsis


St Peters: Did not give antibiotics until four hours after admittance to



First published Friday 20 February 2015 

 by Ellie Cambridge, Reporter - Elm bridge


An investigation into a man’s death found the care he was given at Ashford and St Peter’s Hospital reduced his chances of survival from sepsis.


The 77-year-old was admitted in January 2012 with severe health problems and the severity of his condition was not spotted from more than two hours, until he was seen by a doctor, who suspected he might have sepsis.



Antibiotics were not started until four hours after he was admitted, the Parliamentary and Health Service Ombudsman (PHSO) found.


The investigation by PHSO said the care the man received during the first stage of admission did not meet the expected standard and reduced his chances of recovery.


Julie Mellor, PHSO, said: "Sepsis is a treatable condition, but too many people are dying unnecessarily from it because NHS services are failing to spot the warning signs."


The trust paid his daughter £1,200 in compensation for the distress and to acknowledge and apologise for the failings.


His daughter said: "My father went into hospital with sepsis and never returned home again. Nothing in this world can replace him and all the family are devastated by such a loss."


Suzanne Rankin, chief executive at Ashford & St Peter’s Hospitals NHS Foundation Trust said: "Firstly I would like to offer my personal condolences to this individual family on their loss and I absolutely recognise the devastating impact the passing of a loved one has, particularly in these circumstances.


"Sepsis is a condition that requires urgent treatment and it’s clear that, whilst much of the care given in this case was good, we failed to recognise those early, critical symptoms.


"As indicated by the ombudsman, like many other hospitals we acknowledge that we haven’t been managing sepsis as well as we could and we are fully committed to improving the way we diagnose and treat this critical condition."

Some of the most recent unnecessary deaths are recorded in the “Pages” section on the right hand side of my Blog.

Neil Harris

(a don’t stop till you drop production)