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NHS accused of failing to investigate more than 1,000 deaths

Southern Health NHS FT failed to properly investigate the deaths of more than 1,000 mental health and learning disability patients, according to a leaked report, but the trust strongly contests the findings. 

A leaked copy of the Mazars report, commissioned by NHS England following the death of 18-year-old Connor Sparrowhawk, who drowned at a Southern unit, blames a “failure of leadership” at the trust. 

The study, seen by the BBC, examined all deaths at the trust between April 2011 and March 2015 and found that the trust could “not demonstrate a comprehensive systematic approach to learning from deaths”. 

A spokeswoman for Southern, which runs services in Hampshire, Dorset, Wiltshire, Oxfordshire and Buckinghamshire, said that it fully accepts that its reporting processes following a patient death have “not always been good enough”. 

But she added that there are “serious concerns” about the draft report’s interpretation of the evidence. “We have taken considerable measures to strengthen our investigation and learning from deaths including increased monitoring and scrutiny,” she said. 

“The review has not assessed the quality of care provided by the trust. Instead it looked at the way in which the trust recorded and investigated deaths of people with whom we had one or more contacts in the preceding 12 months. In almost all cases referred to in the report, the trust was not the main provider of care. 

“We would stress the draft report contains no evidence of more deaths than expected in the last four years of people with mental health needs or learning disabilities for the size and age of the population we serve.” 

‘Utterly unacceptable’ 

The report, which claims the trust investigated just 13% of 1,454 unexpected patient deaths, has left many shocked, including the health secretary. Of patients with learning disabilities, only 1% were investigated, and of over-65s with mental health problems, only 0.3% were looked into. 

Speaking in the Commons in response to the leak, Jeremy Hunt said: “It is totally and utterly unacceptable that, according to the leaked report, only 1% of the unexpected deaths of patients with learning disabilities were investigated.” 

He also outlined a three-point plan to improve the situation. 

This includes: From June next year bringing in “Ofsted style” ratings for all Clinical Commissioning Group areas in England; the University of Bristol is to carry out a study into the mortality rates of people with learning disabilities in NHS care; and that from 2016 the number of avoidable deaths will be reported by NHS trusts. 

An NHS England spokesperson said: “We commissioned an independent report because it was clear that there are significant concerns. 

“We are determined that, for the sake of past, present and future patients and their families, all the issues should be examined and any lessons clearly identified and acted upon. 

“The final full independent report will be published as soon as possible, and all the agencies involved stand ready to take appropriate action.” 

Independent investigations 

The report also revealed that despite the trust having comprehensive data on deaths, it failed to use it effectively. And in nearly two-thirds of investigations, there was no family involvement. 

Deborah Coles, director at INQUEST, said: “This report should send shockwaves across the NHS. The failure to investigate deaths of some of society’s most vulnerable people is a scandal that must be urgently addressed. These findings reiterate the need for independent and robust investigations into the deaths of mental health and learning disability patients. 

“What is so disturbing is that this report only came about because of the tireless fight for the truth by the family of Connor Sparrowhawk. This damning report must now prompt a national inquiry. Their families deserve nothing less.” 

Paul Farmer, CEO of Mind, added that there should be an independent inquiry every time someone dies while in the care of the state, and that families should always be involved in any investigation. 

“The NHS must be transparent and accountable in situations such as these and every possible lesson learned to prevent future tragedies,” he said. “It is so important that people receiving treatment and support for their mental health, and their families and loved ones, are able to trust in those providing their care.” 

Luciana Berger, Labour’s shadow minister for mental health, added that the revelations are shocking and, “that if proven, reveal deep failures at Southern health NHS Foundation Trust”.


S Ainsworth   10/12/2015 at 15:45

These claims of alleged failure require looking at more closely. 'Unexpected' deaths are commonplace - ... 46% (229,883 / 500,100) of all registered deaths from 2009 were referred to the coroner. Using the definitions above, it could be suggested that this proportion of all registered deaths in 2009 were unexpected. However, sometimes deaths are referred to the coroner simply because the doctor who knows and has seen the patient in the last 14 days prior to death is not available to sign the death certificate. Analysing the data further, it could be assumed, however, that referrals to the coronial service where no inquest and no post mortem were required were in fact not unexpected deaths because a death certificate could be issued following a discussion between the clinician and coroner only, in which case 22% (229,883-121,765/500,100) of all registered deaths in 2009 could be classified as unexpected. Published by: National End of Life Care Intelligence Network Publication date: February 2011 ISBN: 978-0-9569225-6-4

Tim Whitfield   13/03/2017 at 08:03

how do i find out whether my wife's death in july 2015 was classified as avoidable. she had been in a mental health unit, then transferred to a&e at the adjacent hospital, then transferred to another hospital where she died a week later.

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