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”
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”.
Gosport War Memorial
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.”
Dr 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.