NHS England publishes report into Southern Health

NHS England has today published an independent report into the deaths of people with a learning disability or mental health problem at Southern Health NHS Foundation Trust, and highlighted a system-wide response.

The report was commissioned by NHS England (South) following the death of Connor Sparrowhawk in July 2013 in a unit in Oxford run by Southern Health NHS Foundation Trust.

Both Southern Health NHS Foundation Trust and the clinical commissioning groups (CCGs) that commission services from them have accepted the recommendations.

NHS Improvement (Monitor, as the regulator of Foundation Trusts), NHS England and the Care Quality Commission have set out a joint response to the recommendations which relate to national policy. NHS England has now forwarded the report to Monitor, who will consider as a matter of urgency whether regulatory action is required.

The report will feed into the National Learning Disability Mortality Review Programme which was announced in June.

This three-year project is the first comprehensive, national review set up to get to the bottom of why people with learning disabilities typically die much earlier than average, and to inform a strategy to reduce this inequality.

Jane Cummings, Chief Nursing Officer, said: “Openness, transparency, learning, improving and working with families should be the core tenets of the NHS, especially where things don’t go right.

“We commissioned this report following concerns expressed by Connor Sparrowhawk’s family, and we are grateful for their contribution to this publication.

“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. We have jointly committed to ensure that this and the other actions it sets out are taken.”

Some of the report’s main findings are:

  • 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.

Of the 1,454 deaths recorded at the Trust during this period, 722 were categorised as unexpected by the Trust. Of these 540 were reviewed and 272 unexpected deaths received a significant investigation.  The report does not specify how many investigations there should have been, but draws attention to the limited number of deaths that were investigated in different categories.

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.

Members of the public with queries or concerns about the report can call NHS England’s Customer Contact Centre on 0300 311 22 33 Monday to Friday 8am to 6pm, except Wednesdays when it is open 9.30am to 6pm.


  1. Shahid says:

    NHS need to stop wasting public money they only wake up when things goes wrong managers
    Responsible should be punished if a CCG is not providing good services to patients then Dept of Health have power under constitution to abolish CCG board in my opinion .

  2. Robert Blackman says:

    This should be called the Mazar Maze review – it’s 252 pages of incomprehensible gibberish, punctuated by so many charts, acronyms and tables that one loses one’s way (and one’s will to live) trying to understand its’ purpose. It’s one-sided and biased, with no suggestions for improvement, no mention of the lack of funding for the support of mental health or learning disability patients, and written by a team who appear to have taken leave of their senses. Were they paid by the word? The only thing this review is good for is as a cure for insomnia. I was a Public Governor of Southern Health up to March 2012.

  3. Robert Blackman says:

    • There was no mention of the Trust having to perform under a regime of continual “cost improvement” conditions (budget cuts to the rest of us) imposed by the NHS, nor the effect of these on being able to provide the support many patients will need, both now and in the future.
    • no mention of what might happen if in a GP Practice a proportion of their patients died and who Mazars would seek to blame in that instance.
    • no mention of how difficult it may be for a Trust to engage with carers or families who may have distanced themselves from patients – even when there simply isn’t a carer, friend of family member involved with a patient.
    I am a former Public Governor of Southern Health (up to March 2012)

    • NHS England says:

      The findings of the report and the recommendations made have been accepted. NHS England, the regulators and the Trust are now acting upon these to make improvements at Southern Health and to address the inequalities which we know exist between the care received by people with learning disabilities and mental health problems, and patients with physical illnesses.

    • Willliam Waynflete says:

      The former Public Governor does neither himself nor the Trust any favours by his feeble attempts at excuses and self-justification. A dignified silence would be much more appropriate.

  4. Graham Shaw says:

    What action is being taken against Southern Health Board and management? If none, please explain why. If awaiting the CQC follow-up report, please advise what options are available to you for action? If you don’t know, just say so.

    • NHS England says:

      Employment matters are the responsibility of the Trust Board and the regulators.

      NHS Improvement (Monitor – the regulator of Foundation Trusts) is now considering regulatory action to address failings in governance, highlighted by the report, and to ensure the trust delivers the necessary improvements. The Care Quality Commission has announced that it will be undertaking a full investigation early in the new year. Clinical Commissioning Groups (CCGs) that commission services from Southern Health, alongside Monitor as the regulator of Foundation Trusts, will scrutinise the trust’s improvement actions and delivery. NHS England South Region will hold the CCGs to account for overseeing that improvement.

      The full response to the publication is available here: