What does NHS England's report into Southern Health reveal?
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Recently there has been considerable media comment about whether the chief executive of Southern Health NHS Trust should remain in her position following a report into the way in which a number of deaths were investigated by the Trust.
The debate started from the very tragic death of Connor Sparrowhawk, a boy with learning disabilities who died in July 2013 while he was under care of Slade House NHS Oxford. Connor was allowed to bath unsupervised and behind closed doors despite being known epileptic.
Following this incident, a document was leaked to the public revealing that 10 months prior to his death, there were reported failings that should have raised concerns that the provision of the care in that facility may not have been adequate.
The incident concerning Connor's death, and the subsequent campaign by Connor's family prompted NHS England to commission a report into those individuals with a learning disability or mental health problems who died whilst under the care of Southern Health NHS Trust.
The report prepared in December 2015 found that: ''Southern Health had failed to investigate hundreds of unexpected deaths, and that the likelihood of a death being investigated depended heavily on the patient’s profile. Deaths of learning disabled people were least likely to be investigated. When investigations were carried out, there was a very poor quality of written investigations at all stages.
''The report recommends further action from NHS England and others, in particular that its findings should be shared across England to ensure that deaths are investigated properly. NHS England and Southern Health NHS Trust have jointly committed to ensure that this and the other actions it sets out are taken.”
Some of the report’s main findings include:
- Many investigations were of poor quality and took too long to complete;
- There was a lack of leadership, focus and sufficient time spent in the Trust on carefully reporting and investigating deaths;
- There was a lack of family involvement in investigations after a death;
- Opportunities for the Trust to learn and improve were missed.
The Trust reviewed 1,454 deaths. 772 of those were classified as unexpected. Out to those 772 deaths only 540 were reviewed and 272 have been investigated. NHS England has fully accepted the findings of the final report following a period of review, which included an independent verification of the methodology used.
At BL Claims Solicitors, we are committed to helping our clients who have experienced any failures of care whether that be directly or with their family members. We hope that these findings will be a learning opportunity for all involved, with the aim of improving patient safety and preventing more unnecessary deaths in the future.
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