Jeremy Hunt this morning condemned the apparent failure of leaders at Southern Health to investigate an overwhelming majority of unexpected deaths at the foundation trust as “totally and utterly unacceptable”.
Responding to an urgent question from shadow health secretary Heidi Alexander in the House of Commons today, the health secretary confirmed an NHS England report into avoidable deaths of Southern Health patients would be officially released before Christmas.
“The whole House will be profoundly shocked”
He also pledged to accept the “vast majority if not all of its recommendations”, and did not rule out a public inquiry into the issue.
Parts of a leaked draft of the report, conducted by consultancy Mazars on behalf of NHS England, were revealed yesterday afternoon in an article published by the BBC.
The report was commissioned following the death of Connor Sparrowhawk, 18, at Southern’s short term assessment and treatment unit in Oxfordshire in July 2013. Mr Sparrowhawk, who had autism and epilepsy, died as a result of drowning in a bath following a seizure.
The report found that of 1,454 unexpected deaths, 272 were investigated as a critical incident, and of those, just 195 were reported as serious incidents requiring investigation.
It also criticised the oversight and management arrangements in the trust for reporting deaths.
Mr Hunt said: “It is totally and utterly unacceptable that according to the leaked report only 1% of the unexpected deaths for patients with disabilities were investigated.”
“The whole House will be profoundly shocked” by the allegations, he added.
Ms Alexander said the revelations were “truly shocking”, adding that “the likelihood of a death being investigated depended on the patient”, adding that just 0.3% deaths among older people with mental illness were looked into.
Mr Hunt added that there was an “urgent need” to improve culture around reporting incidents across the system. “We shouldn’t pretend this is about the wrong culture at one trust”, he said.
He outlined three steps to help improve the culture in the NHS around learning disability. These were:
- Independently assessed “Ofsted style ratings” measuring the quality of learning disability services in each clinical commissioning group area, to be published from June
- NHS England have commissioned Bristol University to conduct a study into mortality rates for learning disability patients in NHS care.
- NHS England’s medical director Bruce Keogh is to write to all trusts next week to explain a new methodology he has developed for reporting avoidable deaths at an organisational level. It is expected that the first publications will follow next spring.
Mr Hunt said improving the culture in the NHS was “unfinished business” after the Mid Staffordshire scandal.
Liberal Democrat health spokesman Norman Lamb, who served as a health minister with Mr Hunt in the previous coalition government, mooted a public inquiry into the issue.
He asked Mr Hunt: “Isn’t this the moment where we have to think of something similar [to the Francis report] for people with learning disability or enduring mental health problems?”
The health secretary replied that he was “happy to consider it”, but that his “only hesitation” was that public inquiries can take years, and “I want to take action now”. However, he said he expected Mr Lamb to come back to him if progress was not made.
Dr Sarah Wollaston, chair of the Commons’ health select committee, said the draft report was “deeply disturbing”, and underlined the finding that families were not involved in around two thirds of investigations.