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Leaked report uncovers failure to look into 1,000+ mental health deaths

NHS England commissioned report points finger at trust leadership

Caroline White

Thursday, 10 December 2015

One of England’s largest mental health trusts failed to look into the deaths of more than 1,000 people who died unexpectedly over the past four years, a draft report leaked to the BBC has found.

According to the BBC, the report blames a "failure of leadership" at Southern Health NHS Foundation Trust, which provides services to about 45,000 people in Hampshire, Dorset, Wiltshire, Oxfordshire and Buckinghamshire.

The report was commissioned by NHS England in 2013 following the death of 18-year-old Connor Sparrowhawk, who drowned in a bath after an epileptic seizure while a patient in a Southern Health hospital in Oxford.

The investigation, carried out by audit firm Mazars, looked at all deaths at the trust between April 2011 and March 2015. During that period, 10,306 people died, and 1,454 of these deaths were unexpected.

Of those, 272 were treated as critical incidents, of which just 195 (13%) were treated by the trust as a serious incident requiring investigation, says the BBC.

But the likelihood of investigation depended on the type of patient. While around a third (30%) of deaths among adults with mental health problems were investigated, this proportion dropped to 1% for those with learning disability and 0.3% among the over-65s with mental health issues.

According to the BBC, even when investigations were carried out, they were of poor quality and often extremely late, and the trust didn’t talk to the families of the dead in nearly two thirds of the investigations.

Trust performance failed to improve despite repeated criticism from coroners about the timeliness and usefulness of reports provided for inquests, says the BBC.

The reasons for the failures, the report allegedly says, lie with senior executives and the trust board.

The report's authors conclude: "We have little confidence that the trust has fully recognised the need for it to improve its reporting and investigation of deaths."

In a statement issued to the BBC last night, the trust said: “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.”

The trust had taken steps to improve its procedures in the light of the report, said the statement, including “increased monitoring and scrutiny.”

According to the Guardian Online, the trust said: “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.”

The Patients Association said that it was “appalled” by the findings. “It is hard to believe that another Trust has failed to learn the lessons from Mid-Staffordshire,” said chief executive Katherine Murphy. “It is inexcusable that many of these mental health and learning-disability patients have been judged on their condition and not as a person.”

NHS England has yet to publish the final report.

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