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Southern Health leadership condemned in report on patient deaths


The leaders of Southern Health NHSFoundation Trust have been severely criticised for repeated failures to investigate and learn from patient deaths in an independent report.

The review of deaths of people with learning disability or mental illness who had been in contact with the trust was released yesterday afternoon.

It was conducted by audit firm Mazars for NHS England, in response to the death of 18 year old Connor Sparrowhawk, who had autism and epilepsy, at the trust’s short term assessment and treatment unit in Oxfordshire.

A draft version of the report’s key findings was leaked to the BBC last week.

The full report, published yesterday, said: “There has been a lack of leadership, focus and sufficient time spent on reporting and investigating unexpected deaths of mental health and learning disability service users at all levels of the trust including at the trust board.”

There has also been a “lack of strategic focus relating to mortality”, which had contributed to deaths having “little prominence at board level”, it said.

In addition, the report said “too few deaths were investigated in learning disability and older people’s mental health services”.

However, it noted that it was not possible to say how many deaths should have been investigated that were not, because national guidance on reporting deaths in these services is open to interpretation by trusts.

Investigations that were carried out by the trust were of poor quality overall, making it difficult to learn from these deaths, according to the report.

“There has been a lack of leadership, focus and sufficient time spent on reporting and investigating unexpected deaths”

Mazars report

It said: “There is little evidence that there was any effective effort to improve the quality of the reporting until very recently”, and reports were not rigorously challenged.

There was also an “ad hoc and inadequate approach” to involving families and carers in investigations, stated the report, with two-thirds of investigations relating to mental health having not involved families, while family involvement relating to learning disability was “negligible”.

Meanwhile, the trust did not have a systematic approach to producing action plans, reviews and changing services in response to deaths, and it did not follow its own procedures for serious incident reporting.

Although Southern Health does not have a higher than average mortality rate, the auditors said it appeared to report fewer deaths of mental health service users than other trusts in the region, and compared to the national average.

“It is likely that the low level of reporting is a function of the trust reporting practice,” they said in their report.

“Openness, transparency, learning, improving and working with families should be the core tenets of the NHS”

Jane Cummings

Controversial data on the numbers of deaths investigated was included in the final report. These featured prominently in the section that was leaked in draft form last week, and which were disputed by the trust.

The final report noted that there is no statutory requirement for trusts to report or investigate deaths, except for reporting to the Care Quality Commission. Within the scope of the report, Mazars found that the trust had met its responsibilities under regulation.

The data was disputed in part because Southern Health may not have been the main health provider caring for patients when they died, and so might not have been the most appropriate organisation to investigate the deaths.

However, a new key finding in the final Mazars report, which was not present in the draft, said: “If the trust determine that another part of the system should undertake [an initial assessment of the death] it has a responsibility to ensure the incident is reported to the commissioners.”

Southern Health NHS Foundation Trust

Gosport War Memorial

Gosport War Memorial

Jane Cummings, chief nursing officer for England, said: “Openness, transparency, learning, improving and working with families should be the core tenets of the NHS, especially where things don’t go right.

“The report now recommends further action from us and others, in particular that its findings should be shared across England to ensure that deaths are investigated properly,” she said. ”We have jointly committed to ensure that this and the other actions it sets out are taken.”


Readers' comments (2)

  • michael stone

    Coroners are the people responsible for 'stating why someone died'.

    The issues around 'expected' and 'unexpected' death are more complex when mental health and especially DoLS is involved - nevertheless, the basic methodology which I described in my piece at:

    is still applicable.

    In particular, the two statements from a doctor describing how probable a death is, made in advance, resolve many of the issues, and also allow for proper post-mortem analysis of a region's or organisation's 'processes'.

    If you do what I suggest, the terms 'expected' and 'unexpected' death can be thrown away, which would help as they cannot be sensibly defined !

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  • michael stone

    BBC Radio 4 evening news yesterday told us that 'NHS England said deciding what is, and what isn't, an unexpected death, has proved complicated'.

    It isn't all that complicated, if you 'approach the problem with a clear mind', as I did in the piece I tried to link to in my first comment here - a link, which did not seem to work, when i just tried it.

    So, to get to the piece, you would need to go:


    View the Dignity Champions forum

    Then choose 'Markers and Timelines for End of Life Reconsidered: an attempt to bring order to chaos'.

    The basic methodology, will work in any healthcare setting, including 'complex settings'.

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