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Contested report raises serious concerns over Southern Health deaths


Critical findings in an NHS England-commissioned report into deaths among patients of Southern Health NHS Foundation Trust have been leaked, and strongly contested by the organisation and an academic.

NHS England commissioned the report on the foundation trust, primarily a provider of mental health services, and it examines deaths between April 2011 and March 2015.

“There are serious concerns about the draft report’s interpretation of the evidence”

Southern Health

The work followed 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 new report, by audit firm Mazars, has not been released but the BBC yesterday published extracts in a piece headlined “NHS trust ‘failed to investigate hundreds of deaths’”. It stated: “The NHS has failed to investigate the unexpected deaths of more than 1,000 people since 2011.”

An extract from a version of the Mazars report, seen by Nursing Times’ sister title Health Service Journal, states: “There was a lack of leadership, focus and sufficient time spent in the trust on carefully reporting and investigating unexpected deaths of mental health and learning disability service users.”

The extract said: “1,454 deaths were reported to [reporting system] Ulysses as death incidents. Of these 272 deaths were investigated as a [critical incident report] of which 195 were reported as [serious incidents requiring investigation]…

“There has been no effective systematic management and oversight of the reporting of deaths and the investigations that follow,” it said.

“There was a lack of leadership, focus and sufficient time spent in the trust on carefully reporting and investigating unexpected deaths”

Mazars report

However, a document produced for the foundation trust by an academic in care quality and measurement, looking at what Mazars had found, states that there are significant problems with Mazars’ methodology in relation to numbers of deaths.

In the document, Bradford University professor of healthcare quality and effectiveness Mohammed Mohammed states: “My overall assessment is that the statistical analysis presented by Mazars is at best unsatisfactory, and at worst incompetent. Mazars were tasked with determining if Southern Health is/is not an outlier – they have failed to do this.”

He said the report lacked “rigorous statistical methodology” and had made a significant mistake in its calculation of mortality data. HSJ has contacted Mazars for a response.

 NHS England said it would not release the Mazars report because it was still being worked on. It also said it would not comment on Professor Mohammed’s criticisms until the final version was published. 

The extract of the Mazars report, in addition to discussing the numbers of deaths investigated, criticises the timeliness of investigations. It states: “Despite the board being informed on a number of occasions… the standard of investigation was inadequate.”

In addition, it said the trust has data on deaths but has “failed to use it effectively to understand mortality and issues relating to deaths of its mental health or learning disability service users”.

What the trust said in response

A Southern Health spokeswoman said: “We would not usually comment on a leaked draft report. However, we want to avoid unnecessary anxiety amongst the people we support, their carers and families as their welfare is our priority.

“There are serious concerns about the draft report’s interpretation of the evidence. We fully accept that our reporting processes following a patient death have not always been good enough,” she said. “We have taken considerable measures to strengthen our investigation and learning from deaths including increased monitoring and scrutiny.

“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,” said the spokeswoman.

“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,” she said.

She added: “When the final report is published by NHS England we will review the recommendations and make any further changes necessary to ensure the processes through which we report, investigate and learn from deaths are of the highest possible standard.”


Readers' comments (3)

  • michael stone

    Even for 'normal deaths' - when there are not mental health, or 'detained by the state' issues involved - there are serious problems with the term 'unexpected death' (or indeed the equivalent 'sudden death'). Although I have explained how the biggest problem there, could easily be resolved, in my analysis at:

    But there seems to be something else going on here - the bereaved father I heard on BBC Radio 4 today, was of the opinion that, to use my words, 'the organisation did not value my son's life, because of his mental health issues, as much as it would have valued the life of a 'normal' person' (and I apologise, if I've upset anybody with my phrasing - it was the best I could do !).

    It isn't acceptable, to value some lives less than others - so what was apparently going on, is wrong.

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  • we thought the new layout would discourage spammers such as stone!

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  • michael stone

    10 DECEMBER, 2015 9:46 PM

    Not that I am a 'spammer', your analysis of the consequences of the new NT 'layout' is as dubious as your previous analyses.

    At least you have confirmed that you are a 'we' and not an 'I'.

    I mentioned 'you' in one of my recent pieces on BMJ, by the way:

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