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18.12.15

‘Appalling’ Southern Health deaths review prompts national investigations

Health secretary Jeremy Hunt has announced measures to address the local and wider systemic issues raised in an NHS England report on Southern Health NHS FT – originally prompted by the string of unexpected and preventable deaths of patients in mental health or learning disabilities services since 2011.

Hunt has determined that the CQC will undertake focused inspection at the foundation trust early next year, focusing primarily on its approach to investigating deaths, which the report said lacked leadership, focus and sufficient time commitment.

The inspectorate will assess Southern Health’s progress in implementing the action plan, enforced by Monitor, and in making the necessary improvements highlighted in an earlier February inspection.

But the report pointed to systemic issues in the health service, including the need to do more across all providers to better understand and tackle the deep-seated issue of avoidable mortality.

The CQC will therefore launch a wider review into the investigation of deaths in a sample of all types of NHS trusts, including acute, mental health and community providers, in different regions of the country.

“As part of this review, we will assess whether opportunities for prevention of death have been missed, for example by late diagnosis of physical health problems.

“I am determined that we learn the lessons of this report, and use it to help build a culture in which failings in care form the basis for learning for organisations and for the system as a whole,” Hunt said.

Sir Bruce Keogh and Mike Durkin, NHS England’s medical director and director of patient safety respectively, are writing to trust medical directors offering to help providers with the mortality audit tool, case-note review methodology and reiterating the government’s commitment to deliver medical examiners.

They will set out how to use the audit tool to supply data that supports better understanding and improvement, Hunt said.

The Learning Disability mortality review will act as a repository for anonymised reports linked to people with learning disabilities from several sources – in particular, anonymous copies of ‘series case reviews’ and Ombudsman reports. The project, expected to support improvement across the board, will start in January 2016.

Background

The NHS England-commissioned independent report, published yesterday, was originally requested by the family of Connor Sparrowhawk, who suffered a preventable death in July 2013. They asked for a review of all deaths of patients involved in the trust’s mental health and learning disabilities services between April 2011 and March 2015, as their relative had been.

The report found that of the 1,454 deaths recorded during this period, 722 were categorised as unexpected. Of these, 540 were reviewed and only 272 received a ‘significant investigation’.

Although the document did not specify how many investigations there should have been because national guidance is open to trust discretion, it argued too few deaths were investigated. For example, only 1% of deaths in learning disability services were investigated as ‘critical incident reviews’.

It also identified a serious “lack of leadership, focus and sufficient time spent in the trust on carefully reporting and investigating unexpected deaths” across mental health and learning disability service users.

There was no effective systematic management and oversight of the reporting of deaths or the investigations that followed, despite it being “reasonable to expect” the trust to properly review the need for further investigation after staff report concerns to their incident management system.

Timeliness was another major concern, with the trust taking around 10 months between an incident and the end of an investigation. Afterwards, it failed to demonstrate a “comprehensive and systematic approach” to learning from the deaths, as evidenced by board review, action plans and service changes.

More widely, the report said NHS England must highlight learning from this review for other trusts. The body must also develop guidance on an assurance framework for mental health ad learning disability deaths, and require trusts to include this on their board assurance arrangements.

‘No room for complacency’

NHS Improvement’s chief executive designate, Jim Mackey, said: “There is no room for complacency and when there are mistakes or the service falls short of expectations, we have a responsibility to get a grip of the situation, learn lessons and make the necessary improvements.

“We accept the recommendations made in today’s report and will work hard with colleagues at the CQC and NHS England to ensure that the lessons are learned and that improvements are made.”

The CQC’s deputy chief inspector of hospitals, Dr Paul Lelliot, also welcomed and accepted the report, reiterating its commitment to undertake both focused and wider inspections and work alongside NHS England, Monitor and the Health and Safety Executive.

Southern Health’s chief executive, Katrina Percy, accepted that the provider’s processes for reporting and investigating deaths were “not always as good as they should have been”.

“In the past, our engagement with families and carers of people who have died in our care has not always been good enough. Whilst we have already made substantial changes in how we approach this, we have more improvements to make,” she added.

“Reports such as this challenge not only Southern Health, but the wider health and social care system, and society as a whole, to reflect on the way we support, include, and value people with learning disabilities and mental health needs. All providers and commissioners of care can learn from this report.”

Luciana Berger MP, shadow minister for mental health, said the findings were “shocking and appalling”, adding: “It is all the more worrying that this investigation would not have happened if not for the determination of the families who lost loved ones to seek answers.

“Just because some individuals have less ability to communicate concerns about their care must never mean that any less attention is paid to their treatment or their death.

“Ministers must take urgent steps to improve openness and transparency within our NHS, ensure unexpected deaths are fully investigated and that lessons are learned to prevent future deaths.”

(Top image c. Neil Hall and PA Wire)

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