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Southern investigates ‘very few’ learning disability deaths, e-mails reveal

E-mails released under the FOI Act show that the principal concern from the CQC which led to it issuing the troubled Southern Health trust with a warning notice was the organisation’s consistent failure to investigate the deaths of patients with learning disabilities.

The CQC’s latest inspection, published last month, found that the trust is still failing to learn from deaths and manage risk despite repeated warnings. It led to the resignation of Mike Petter as the trust’s chair and the appointment of Tim Smart as his replacement by NHS Improvement.

In a newly released e-mail, sent to his colleagues Mike Richards and David Behan on 13 December last year, Dr Paul Lelliott, deputy chief inspector of hospitals at the CQC, said that Southern did not have an unusually high death rate.

However, he said: “I agree that the main concerns are the poor quality of and delay in investigating deaths and the trust’s decisions about what deaths it does investigate; especially the fact that it investigates very few deaths of people with learning disabilities.”

Concerns were first raised about Southern after the Mazars report into the trust, commissioned after 18-year-old patient Connor Sparrowhawk drowned in a bathtub at a Southern hospital, found that just 13% of 1,454 unexpected patient deaths were investigated.

The e-mails show that Southern investigated 51% of reported deaths of adult mental health patients, but just 4.5% of deaths of users of old age mental health services and 2.5% of deaths of learning disability patients.

Trust staff logged 47% of deaths of learning disability patients in their incident reporting system, compared to 60% of deaths among working age services users and 9% of deaths among old age mental health users.

Southern conducted an initial management assessment of 64 deaths of learning disability patients, which led to investigations of two of these deaths.

For comparison, initial assessments were carried out on 202 adult mental health deaths, resulting in 76 investigations, and 56 on elderly mental health patients, leading to three investigations.

A further two deaths of people in contact with learning disability services were treated as serious incidents, compared to 161 in adult mental health and 31 in old age mental health.

The disclosure comes as Tim Smart cancelled an extraordinary meeting of trust governors which would have taken place tomorrow and included a motion for a vote of no confidence in the executive board, according to the BBC.

Peter Bell, one of the governors, told the BBC that he was considering legal action if the meeting did not go ahead.

He said: "If this was not such a serious matter I would be laughing out loud at such tactics. But this is no laughing matter. This is deadly serious and I really hope that the interim chair begins to understand just how serious this is. Do we really need to resort to the courts in the first two weeks of your appointment?"

(Image: Ravenswood House, Fareham. c. Peter Facey)

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