River House incident's investigation report

The request was partially successful.

Dear South London and Maudsley NHS Foundation Trust,

An independent investigation was commissioned to investigate the incident that happened on 2012-10-01 at River House at Bethlem Royal Hospital. It was due to be completed early 2013, however on 2012-11-08 and 20 2013-03-20 you responded to two previous FoI requests about this investigation that it was still ongoing. It is now more than eight months since the incident occurred, so hopefully the report has been received and ratified.

In compliance with the FoI act, can you please send me a copy of this investigation report.

If some further delays have occurred and this report is still not available, please inform me of when you expect for it to eventually become available.

Yours faithfully,

David Mery

David Mery left an annotation ()

Previous FoI requests about this investigation report:
https://www.whatdotheyknow.com/request/r... (2012-10-30)
https://www.whatdotheyknow.com/request/r... (2013-02-21)

Kazeem, Toyin, South London and Maudsley NHS Foundation Trust

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[1]Picture (Device Independent
Bitmap)

Information Governance Office

Clinical Records-CR2

Maudsley Hospital

Denmark Hill

London SE5 8AZ

Email: [2][South London and Maudsley NHS Foundation Trust request email] 

Dear Mr Mery,

I am writing to acknowledge receipt of your request for information
regarding River House incident's investigation report.  Your request was
received on 11^th June 2013 and we are dealing with it under the terms of
the Freedom of Information Act (2000).

We aim to provide you with the information requested within the 20 working
days. In certain exceptional circumstances a fee may be payable and if
that is the case, I will let you know the likely charges before
proceeding.  You will receive a notification if an exemption applies to
the disclosure of this information under the Freedom of Information Act
(2000).

If you have any queries about this letter, please contact us at
[3][South London and Maudsley NHS Foundation Trust request email]

Yours sincerely,

Ms Toyin Kazeem
Information Governance Assurance Officer.
South London and Maudsley NHS Foundation Trust
Information Governance Office | Maudsley Hospital | CR2 | Denmark Hill |
London| SE5 8AZ

Visit our website http://www.slam.nhs.uk/

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Kazeem, Toyin, South London and Maudsley NHS Foundation Trust

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Dear Mr Mery,

Please find attached response to your request for information.

Regards

Ms Toyin Kazeem
Information Governance Assurance Officer
South London and Maudsley NHS Foundation Trust
Information Governance Office | Maudsley Hospital | CR2 | Denmark Hill | London| SE5 8AZ
Follow us on Twitter for information governance tips: www.twitter.com/maudsleyNHS_IG

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Dear Ms Kazeem,

Thank you for your response. I look forward to the eventual, much delayed, publication of this report within the next 22 days.

Yours sincerely,

David Mery

Dear Ms Kazeem,

I could not find the investigation report on the SLaM website and would very much appreciate if you could provide me with a direct link to it.

Yours sincerely,

David Mery

Dear South London and Maudsley NHS Foundation Trust,

Please pass this on to the person who conducts Freedom of Information reviews.

I am writing to request an internal review of South London and Maudsley NHS Foundation Trust's handling of my FOI request 'River House incident's investigation report'.

This request was exempted was exempted using section 22 of the act (intended for future publication). I was informed that 'The independent investigation of the incident that took place at River House, Bethlem Royal Hospital has been completed. The Trust is aiming to publish the report by the end of July on the website at www.slam.nhs.uk.'

The incident happened in October 2012. The report was initially supposed to be published in January 2013. The response to my request states that the report has been completed.. More than 10 months after the incident, and well after the latest publication deadline of 'end of July', this report has still not been published.

Furthermore the section 22 exemption that was used must be qualified by a public interest test. In breach of the act, no such public interest test was provided in the response. Considering the large attendance at the public events organised by SLaM and BMH UK, and that an earlier police intervention on a SLaM ward resulted in a death, it is clear there's a strong public interest in favour of publication of this investigation report.

A full history of my FOI request and all correspondence is available on the Internet at this address: https://www.whatdotheyknow.com/request/r...

Yours faithfully,

David Mery

Tunmore, Ben, South London and Maudsley NHS Foundation Trust

1 Attachment

Dear Mr Mery,

 

Please find attached the response to your freedom of information request.

 

Regards, Ben

____________________________________________________________

Ben Tunmore

ICT Compliance Manager,

South London and Maudsley NHS Foundation Trust 

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Dear Ben Tunmore,

Thank you for the review by Murat Soncul and the eventual publication of the report, however the review is lacking in that it did not address the breach of the FoI Act in using the section 22 exemption without providing a public interest test.

To ensure better compliance with the FoI Act in the future I would very much appreciate an admission of this breach and an apology. This would conclude my concern in this matter.

(The ICO has published a helpful guide for FoI teams in how to use this exemption at http://www.ico.org.uk/for_organisations/... )

Yours sincerely,

David Mery

David Mery left an annotation ()

The report has eventually been published at http://www.slam.nhs.uk/about-us/policy-a... and the direct link to the PDF is http://www.slam.nhs.uk/media/200782/Inde...

Dear Ben Tunmore,

Further to my earlier email about the internal review not having addressed my concern about the breach of the FoI Act in using the section 22 exemption without providing a public interest test, I have now had the time to read through the report and noticed other serious breaches of the act that will need to be addressed.

The published document has entire sections that are deleted (for example there are gaps between sections 3.2 and 3.3, 3.3 and 3.5, 3.7 and 3.10) and the published report ends with section 3.18, when on p.9, the following text is included 'examples provided by the BDP CAG in section 17 of this Independent report' so sections 3.19 to 17 included are also missing and possibly more. There is no indication of of how much text you have redacted.

Also missing are the names and qualifications of the authors of this independent investigation, essential information to give it credibility.

Yet another serious breach of the FoI Act is that no exemption has been listed to justify any redaction. (I note in the introduction that 'This report refers to ten patients, whom for the purposes of confidentiality have been anonymised (referred to as patients A to J), as have staff and other individuals referred to in this report.' so any missing text is obviously not for confidentiality reasons as this has already been taken care of by the unlisted report authors.)

May I draw your attention to the ICO guidance on withholding only parts of a document at http://www.ico.org.uk/for_organisations/...

I look forward to receiving a prompt response addressing these serious issues or at the very least a prompt indication of when you will be able to respond substantively.

Yours sincerely,

David Mery

Kazeem, Toyin, South London and Maudsley NHS Foundation Trust

Dear Mr Mery,
I am writing to acknowledge receipt of your request for an internal review of the response sent to you on 28th August 2013.

Regards

Ms Toyin Kazeem
Information Governance Assurance Officer
South London and Maudsley NHS Foundation Trust
Information Governance Office | Maudsley Hospital | CR2 | Denmark Hill | London| SE5 8AZ
Follow us on Twitter for information governance tips: www.twitter.com/maudsleyNHS_IG

show quoted sections

Kazeem, Toyin, South London and Maudsley NHS Foundation Trust

1 Attachment

Dear Mr Mery,
Please find attached response to your request for an internal review.

Regards

Ms Toyin Kazeem
Information Governance Assurance Officer
South London and Maudsley NHS Foundation Trust
Information Governance Office | Maudsley Hospital | CR2 | Denmark Hill | London| SE5 8AZ
Follow us on Twitter for information governance tips: www.twitter.com/maudsleyNHS_IG

show quoted sections

Dear Toyin Kazeem and Murat Soncul,

Many thanks for your internal review, however as it doesn't fully address the issues I raised I will have to apply to the ICO for a decision.

Yours sincerely,

David Mery

Soncul, Murat, South London and Maudsley NHS Foundation Trust

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Dear Mr Mery,

 

RE: ICO Complaint Reference - FS50514652

 

I am writing in relation to your request for information following a news
article published on the News Shopper website in relation to the incident
that took place on 1 October 2012 at River House, Bethlem Royal Hospital.
You requested the investigation report of this incident under the Freedom
of Information Act (2000).

 

The Trust published the report with redactions on its website on 29 August
2013 and you were notified of the imminent publication prior to this date.
You subsequently requested an internal review as you were not satisfied
with the redactions in the report. The Trust undertook this internal
review as requested and responded to you on 27 September 2013 with an
explanation of the redactions applied in line with relevant exemptions of
the Act. As you were not satisfied with the outcome of the internal
review, you complained to the Information Commissioner’s Office.

 

Following your complaint, the Information Commissioner’s Office has
undertaken an independent assessment. As a result of this assessment, I am
writing to provide you a lesser redacted version of the investigation
report. The additional sections that are provided in this version have
been highlighted  in yellow and redacted sections have been highlighted in
black for ease of reference. 

 

Please ignore my previous email sent on 26 February 2014.

  

I have copied this correspondence to the Information Commissioner’s Office
for their information.

 

Yours sincerely,

 

Murat Soncul

Head of Information Governance

South London and Maudsley NHS Foundation Trust

 

Cc. Information Commissioner’s Office

 
 

Visit our website [1]www.slam.nhs.uk

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Soncul, Murat, South London and Maudsley NHS Foundation Trust

1 Attachment

 
 

Dear Mr Mery,

 

RE: ICO Complaint Reference - FS50514652

 

I am writing in relation to your request for information following a news
article published on the News Shopper website in relation to the incident
that took place on 1 October 2012 at River House, Bethlem Royal Hospital.
You requested the investigation report of this incident under the Freedom
of Information Act (2000).

 

The Trust published the report with redactions on its website on 29 August
2013 and you were notified of the imminent publication prior to this date.
You subsequently requested an internal review as you were not satisfied
with the redactions in the report. The Trust undertook this internal
review as requested and responded to you on 27 September 2013 with an
explanation of the redactions applied in line with relevant exemptions of
the Act. As you were not satisfied with the outcome of the internal
review, you complained to the Information Commissioner’s Office.

 

Following your complaint, the Information Commissioner’s Office has
undertaken an independent assessment. As a result of this assessment, I am
writing to provide you a lesser redacted version of the investigation
report. The additional sections that are provided in this version have
been highlighted  in yellow and redacted sections have been highlighted in
black for ease of reference. 

 

Please ignore my previous email sent on 26 February 2014.

  

I have copied this correspondence to the Information Commissioner’s Office
for their information.

 

Yours sincerely,

 

Murat Soncul

Head of Information Governance

South London and Maudsley NHS Foundation Trust

 

Cc. Information Commissioner’s Office

 
 

Visit our website [1]www.slam.nhs.uk

Disclaimer
This e-mail and any files transmitted with it are confidential. If you are
not the intended recipient, any reading, printing, storage, disclosure,
copying or any other action taken in respect of this e-mail is prohibited
and may be unlawful. If you are not the intended recipient, please notify
the sender immediately by using the reply function and then permanently
delete what you have received. Incoming and outgoing e-mail messages are
routinely monitored for compliance with the Department of Health's policy
on the use of electronic communications. For more information on the
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References

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Soncul, Murat, South London and Maudsley NHS Foundation Trust

1 Attachment

 
Dear Mr Mery,

 

RE: ICO Complaint Reference - FS50514652

 

I am writing in relation to your request for information following a news
article published on the News Shopper website in relation to the incident
that took place on 1 October 2012 at River House, Bethlem Royal Hospital.
You requested the investigation report of this incident under the Freedom
of Information Act (2000).

 

The Trust published the report with redactions on its website on 29 August
2013 and you were notified of the imminent publication prior to this date.
You subsequently requested an internal review as you were not satisfied
with the redactions in the report. The Trust undertook this internal
review as requested and responded to you on 27 September 2013 with an
explanation of the redactions applied in line with relevant exemptions of
the Act. As you were not satisfied with the outcome of the internal
review, you complained to the Information Commissioner’s Office.

 

Following your complaint, the Information Commissioner’s Office has
undertaken an independent assessment. As a result of this assessment, I am
writing to provide you a lesser redacted version of the investigation
report. The additional sections that are provided in this version have
been highlighted  in yellow and redacted sections have been highlighted in
black for ease of reference. 

 

Please ignore my previous email sent on 26  and 27  February 2014.

  

I have copied this correspondence to the Information Commissioner’s Office
for their information.

 

Yours sincerely,

 

Murat Soncul

Head of Information Governance

South London and Maudsley NHS Foundation Trust

 

Cc. Information Commissioner’s Office

 
 

Visit our website [1]www.slam.nhs.uk

Disclaimer
This e-mail and any files transmitted with it are confidential. If you are
not the intended recipient, any reading, printing, storage, disclosure,
copying or any other action taken in respect of this e-mail is prohibited
and may be unlawful. If you are not the intended recipient, please notify
the sender immediately by using the reply function and then permanently
delete what you have received. Incoming and outgoing e-mail messages are
routinely monitored for compliance with the Department of Health's policy
on the use of electronic communications. For more information on the
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References

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Soncul, Murat, South London and Maudsley NHS Foundation Trust

1 Attachment

 

 

Dear Mr Mery,

 

RE: ICO Complaint Reference - FS50514652

 

I am writing in relation to your request for information following a news
article published on the News Shopper website about the incident that took
place on 1 October 2012 at River House, Bethlem Royal Hospital. You
requested the investigation report of this incident under the Freedom of
Information Act (2000).

 

As you know, the Trust has previously withheld some aspects of the Report
from disclosure by applying the exemptions in sections 38 (health and
safety) and 40 (personal data) of the Freedom of Information Act (2000).

 

Following your complaint, the Information Commissioner’s Office has
undertaken an independent assessment. The Trust has now resolved to
withdraw its use of the exemptions in sections 38 and 40 of the Freedom of
Information Act (2000) to the Report and to disclose it in an un-redacted
form. Please find attached.

 

I have copied this correspondence to the Information Commissioner’s Office
for their information.

 

Yours sincerely,

 

Murat Soncul

Head of Information Governance

 

Cc. Information Commissioner’s Office

Visit our website [1]www.slam.nhs.uk

Disclaimer
This e-mail and any files transmitted with it are confidential. If you are
not the intended recipient, any reading, printing, storage, disclosure,
copying or any other action taken in respect of this e-mail is prohibited
and may be unlawful. If you are not the intended recipient, please notify
the sender immediately by using the reply function and then permanently
delete what you have received. Incoming and outgoing e-mail messages are
routinely monitored for compliance with the Department of Health's policy
on the use of electronic communications. For more information on the
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References

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David Mery left an annotation ()

The full saga to get SLaM to be more transparent about this incident (and hopefully more generally) is published at http://gizmonaut.net/blog/uk/2014/03/SLa...

Following the publication of the unredacted version (though one of the previously sent in blacked out version still had the blacked out text in the pdf), my complaint to the ICO has only one remaining unaddressed issue: the report has three sections, but mentions on p.10 'section 17'. Either this is a typo or there are still some missing sections.

Ganesh Sittampalam left an annotation ()

The Trust's message of 27th February included a copy of the document that had been badly redacted by overlaying black boxes on the text, which meant that the redacted text could be revealed using copy and paste.

The Trust contacted us shortly afterwards to ask that we remove this document from the site. In line with our policy, we temporarily hid it from public view while we discussed the situation internally and with the Trust.

As a number of the redactions did not appear to be properly explained by the refusal notice sent on 27th September 2013, and did not appear to be really justified at all, we asked them to give further details of why the material should be hidden.

The Trust then followed up with a letter from external solicitors that repeated their request to remove the document but did not provide any further explanation of the redactions. We followed up repeating our request that they explain why the material should be hidden but got no reply.

One example of an apparently improper redaction was the name of the communications equipment used by the staff, despite the fact that the Trust uses the equipment being advertised on the manufacturer's own website.

As an unredacted document has now been released we have now also unhidden the original badly redacted document in the interests of making the full history properly visible.

Ganesh - WhatDoTheyKnow volunteer

Soncul, Murat, South London and Maudsley NHS Foundation Trust

1 Attachment

Dear Mr Mery,

 

Please find attached letter in relation to your complaint to the ICO.

 

Yours sincerely,

 

Murat Soncul

Head of Information Governance

 

Cc. Mr Alun Johnson, Senior Case Officer, ICO

Visit our website [1]www.slam.nhs.uk

Disclaimer
This e-mail and any files transmitted with it are confidential. If you are
not the intended recipient, any reading, printing, storage, disclosure,
copying or any other action taken in respect of this e-mail is prohibited
and may be unlawful. If you are not the intended recipient, please notify
the sender immediately by using the reply function and then permanently
delete what you have received. Incoming and outgoing e-mail messages are
routinely monitored for compliance with the Department of Health's policy
on the use of electronic communications. For more information on the
Department of Health's e-mail policy click [2]here

References

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Dear Mr Soncul,

Thank you for your progress letter. I look forward to the publication later this month of the document you had overlooked.

Yours sincerely,

David Mery

Soncul, Murat, South London and Maudsley NHS Foundation Trust

1 Attachment

 

Dear Mr Mery,

 

Please find attached letter in relation to your complaint to the ICO.

 

Yours sincerely,

 

Murat Soncul

Head of Information Governance

 

Cc. Mr Alun Johnson, Senior Case Officer, ICO

Visit our website [1]www.slam.nhs.uk

Disclaimer
This e-mail and any files transmitted with it are confidential. If you are
not the intended recipient, any reading, printing, storage, disclosure,
copying or any other action taken in respect of this e-mail is prohibited
and may be unlawful. If you are not the intended recipient, please notify
the sender immediately by using the reply function and then permanently
delete what you have received. Incoming and outgoing e-mail messages are
routinely monitored for compliance with the Department of Health's policy
on the use of electronic communications. For more information on the
Department of Health's e-mail policy click [2]here

References

Visible links
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Dear Mr Soncul,

Thank you for the publication of this document. The redactions are extensive and in several instances appear to be outside the scope of the two claimed exemptions.

Yours sincerely,

David Mery

David Mery left an annotation ()

This latest response is the focus of a supplementary evidence to the Home Affairs Committee's inquiry into Policing and Mental Health:
http://gizmonaut.net/blog/uk/2014/06/hac...

David Mery left an annotation ()

The ICO has decided agains SLaM that it must unredact its full report by March 25th. Link to the decision notice at http://gizmonaut.net/blog/uk/2015/01/ico...

Soncul, Murat, South London and Maudsley NHS Foundation Trust

1 Attachment

Dear Mr Mery,

Please find enclosed letter in response to your complaint to the Information Commissioner's Office and the subsequent decision notice by the ICO.

Yours sincerely,

Murat Soncul
Head of Information Governance
South London and Maudsley NHS Foundation Trust

Visit our website http://www.slam.nhs.uk/

Disclaimer
This e-mail and any files transmitted with it are confidential. If you are not the intended recipient,
any reading, printing, storage, disclosure, copying or any other action taken in respect of this e-mail is prohibited
and may be unlawful. If you are not the intended recipient, please notify the sender immediately by using the reply
function and then permanently delete what you have received. Incoming and outgoing e-mail messages are routinely monitored
for compliance with the Department of Health's policy on the use of electronic communications. For more information on the
Department of Health's e-mail policy click here http://www.doh.gov.uk/emaildisclaimer.htm

Dear Mr Soncul,

Thank you for this version of the report. I am still going through it, but I have already spotted what appears to be some mistakes in your redactions:

On p. 33, the just-published version include 'In the absence of the October on-call rota, reception staff wrongly identified xxxxxxxxxxx xxx xx instead of xxxxx.”' when the previously heavily redacted version had '“In the absence of the October on-call rota, xxxxxxxxxxxxxxxxxxxxx wrongly identified zzzzzzzz as on-call xxx instead of xxxx.”'

This means that you've introduced at least one new redaction that of 'as on-call '.

Also on p. 70, the just-published version include 'The post was held for a short period of time by xxxx until January 2013, followed by xxxx . xxxx has recently been appointed and is due to take up her post 13th May 2013.' when the previously heavily redacted version had 'The post was held for a short period of time by one of the xxxxx'.

This means that you've introduced at least one new redaction that of 'one of the'.

Also on p. 70 in 'Shortly after the opening of RH, discussions with [the] xxxxxxx', this second 'the' was redacted in the just-published version.

I would very much appreciate if you can check that you didn't still over-redact any other occurrences, in particular pp. 40-65 are still nearly entirely redacted.

Yours sincerely,

David Mery

David Mery left an annotation ()

Some extracts from this report, as well as the status of the remaining redactions, are written about at http://gizmonaut.net/blog/uk/2015/04/wha...

John Cross left an annotation ()

David Mery left an annotation ()

Thanks John, I included both the Independent and the I news stories and linked to all the versions of the report at http://gizmonaut.net/blog/uk/2015/05/mps...

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