[2025] EWHC 2684 (KB)

As for extra staffing required to implement extra care it is stated in the document that;

“To provide extra care service staff of a variety of disciplines may be deployed, as necessary, to maximise the potential for inclusion of service users who display challenging behaviour in every appropriate part of the programme. Often, most senior and experienced clinicians will focus on that individual, providing greater input than they would normally receive at that level. Some staff replacement cost may be incurred in additional numbers on the shift to enhance the service users opportunity for participation and to enable regular staff to provide additional time to them. However, this is not one to one nursing or “specialling” and consequently chancellor care is able to keep the cost to less than half that charge by some providers.” (underlining added)

And

“When planning the opening of the hospital and knowing the client group that would be using our facilities, it was clear that some persons would experience symptoms that made life very difficult for them. Engaging in the treatment programmes would therefore be a very real challenge…… to enable us to attempt full patient engagement with their programme, extra staff from a variety of disciplines were employed over and above the minimum/core element.”

And

“extra care facilitates us, as the provider, to take a therapeutic risk in order to achieve better, longer term, clinical outcomes. It presents a financial risk to us, the provider, in terms of a substantial initial outlay for extra substantive staff, further additional staffing required and the replacement/repair of any damaged items or property, which may or may not be recovered in their entirety through the extra care charge.”

The explanations of using/paying for further additional staffing required and for staff replacement costs can be contrasted with the evidence of Mr Deveney and as to staffing levels generally.

As I shall set out in due course in an e-mail sent on the 20^th October 2006 Mr Ward was critical of the draft document as it stated what extra care was not but failed to clearly set out what it was.

Ms Ventham referred to the police statement of Mr McKenzie who became the Chief Operating officer in July 2006 (originally having trained as a mental health nurse then progressing to a ward manager and then director of nursing at other hospitals) and suggested that it showed how opaque the extra care charge was for him and how it did not operate as he would have expected. Mr McKenzie said that having reviewed such procedures and policies as there were (and the PwC report) before he started he thought that extra care was another term for specialling. Mr McKenzie stated that it was after a board meeting on 4^th September 2006 he started to ask some questions and found that three patients were still subject to extra care charges. He said that he had never heard about the concept and it sounded like something called zonal observation whereby patients are nursed in an environment where they could be easily observed; but that neither the Manor or the Grange at Cawston Park lent themselves to this type of concept. He stated;

“This being the case the whole concept sounded rather flowery (in interview the term used was “a bit blurry”) and I couldn't see that those patients were necessarily getting anything extra. I cannot find any audit trail as to why any of these remaining extra care patients were subject to an extra care charge. However we have commissioned an internal investigation that may report differently on this activity. I don't know how it was decided who would be on extra care. Logically this would be a clinical decision made at ward round. Ideally the RMO taking a lead in this. I'm unclear how decisions were communicated to finance at this point. A record would be made by the clinician in the patient’s notes about their needs. This would cover provision of extra staff. Through constant review the RMO should decide how long this was necessary for. During September and October 2006, having learned about the investigation, I made inquiries with the unit managers, Mark Grainger, Phil Wakely and Helen Walters and asked them to explain extra care. I learned that it wasn't specialling, and Dominic tried to explain that it was about patients being provided with extra services such as clinicians giving more input but ultimately no one could give in my view a reasonably straightforward easy to understand definition. On one occasion I asked Mark Grainger how many patients he had on extra care. He did not know…On the basis of what I know of extra care and the lack of detail about it, the only people that could deliver it would have been Mark Deveney, Dr Simon Barker and Andrew Breeze. How they could actually do this I do not know.”

Mr McKenzie suggested the practice of extra care charges stop. Given that Mr McKenzie was supposed “to run the place operationally” as Chief Operating Officer and commenced employment in the summer of 2006 it is unsurprising that Ms Ventham raised its contents (which were accurately summarised in the case summary). The statement had also been put to Mr Breeze during his interview. It was set out in the case summary that;

“Breeze said that his response would be to say that McKenzie had got it wrong. McKenzie had come from a mainstream psychiatric healthcare company and didn't understand the concept of the way they worked. They didn't feel the need to start making heavy explanations as to what extra care was all about because they had stopped charging for it…The reason McKenzie was unable to found out (sic) about extra care was that he had not spoken to Breeze..”

So Mr Breeze acknowledged that his own chief Operating officer did not understand the charge and would not get an explanation for its levying that he could understand. (Mr McKenzie stating that it was still being charged at the time of the police raid).

As with Mr Breeze there was a very lengthy “precis” of Mr Wilson’s interviews in the case summary and DS Brownsell was not challenged as to its accuracy.