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CQC issues warning notice to Southern Health over safety

  • 8 Comments

The Care Quality Commission has issued a warning notice to Southern Health NHS Foundation Trust, requiring the troubled organisation to take urgent action to improve its arrangements for ensuring patient safety.

In a statement on Wednesday afternoon, the regulator said the trust had failed to address “significant risks” posed by the physical environment and its arrangements to ensure proper investigations of incidents, including deaths, were inadequate.

“It is only now, following our latest inspection, and in response to the warning notice, that the trust has taken action”

Paul Lelliott

The regulator visited the trust in January as part of a focused inspection after the publication of a report by the audit firm Mazars, which highlighted failures to investigate and learn from patient deaths.

The inspection report is not expected to be published until the end of the month, so the CQC is restricted in what detail it can currently share on its findings. However, the CQC issues warning notices where it is concerned that a provider must make urgent changes after an inspection which cannot wait for the publication.

In its statement the CQC said it had issued Southern Health with a warning notice “requiring the trust to improve its governance arrangements to ensure robust investigation and learning from incidents and deaths, to reduce future risks to patients”.

Inspectors found the trust had “failed to mitigate significant risks posed by some of the physical environments”.

Southern Health NHS Foundation Trust

Gosport War Memorial

Gosport War Memorial Hospital

The trust “did not operate effective governance arrangements to ensure robust investigation of incidents, including deaths” and did not ensure it “learned from incidents to reduce future risks to patients”.

Paul Lelliott, CQC’s deputy chief inspector of hospitals, said the regulator had found “longstanding risks to patients, arising from the physical environment, that had not been dealt with effectively”.

He added: “It is only now, following our latest inspection, and in response to the warning notice, that the trust has taken action and has identified further action that it will take to improve safety at Kingsley ward, Melbury Lodge and Evenlode in Buckinghamshire.”

Care Quality Commission

Dr Paul Lelliott

Paul Lelliott

The fact that CQC found risk relating to the physical environment was especially concerning.

The Mazars report was commissioned by NHS England following the death of 18 year Connor Sparrowhawk, who drowned in a bath at Southern’s short term assessment and treatment unit in Oxfordshire in July 2013.

A jury inquest found that Mr Sparrowhawk, who had autism and epilepsy, died as a result of drowning following a seizure, and that his death was contributed to by neglect.

  • 8 Comments

Readers' comments (8)

  • Dear Jeremy Hunt is this yet another UK failed lean approach? If true Mark Graban if your out there take note.

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  • Am I wrong or was there something about the local council and social workers keeping quiet? It would seem there is a bigger issue here. How can so many situations not result in criminal action being taken against Southern's management? Smacks of something funny going on to me!

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  • I bet this doesn't make NHS England or the now NHS Improvement involvement of the lean 10 look very good.....

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  • Let's be honest poor leadership and poor method is one in the same. The problem is the powers that be are in denial and its the masses that are thought to be wrong. Their answer seems to be send in more of the same with better leadership.

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  • What about the Commissioners?

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  • Commissioners = concern to high quota of ex NHS Managers and those who won't rock the boat or term anything too controversial as subjective so as to avoid complaint against their own register. Should be asking why hasn't the HSE given them a find or police arrested senior management. Where we're the unions as well? Just like mid staffs the union and CQC responded too little too late.

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  • Apparently if I read right, although just a view; NHS Improvement are trying to get the commission to collude with them in regard to the rubbish American approach - that if right (could be wrong) in regard to the sbove has potentially cost lives. Yes that's right NHS Improvement were watching you carefully. You might think their leadership is bad but more of the same helps no one. In my book NHS Improvement = cost cutting

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  • Definitely something more to this

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