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.