Stage 2 Independent Investigation into Southern Health NHS Foundation Trust: September 2021

A recommendation of the Stage 1 Independent Report into Southern Health NHS Foundation Trust in February 2020 was a limited public investigation into a small number of specific policies and processes to determine the extent of progress and to make further recommendations for the Trust. These issues were:

Reviewing the need for a new independent investigative process
The handling of complaints
Communication and liaison with service users, carers and families
Action plans
Supervision by West Hampshire CCG of those issues

Here is the stage 2 report from the Independent Investigation Panel, Chaired by Mr Pascoe QC.

Here are extracts of the stage 2 report featuring the Executive Summary, Recommendations and Conclusions.

Here is an easy read version of the stage 2 Independent Investigation report.

Stage 2 Independent Public Investigative Hearing into Southern Health NHS Foundation Trust

This Independent Public Investigative Hearing is chaired by Mr Nigel Pascoe QC leading an independent panel.

Public Hearing dates

The Public Hearing sessions will begin at 10:30 on Thursday 4 March 2021. They will start with a statement from the Chair of the Independent Panel.

The Public Hearing sessions will conclude on 29 April 2021.

Due to the Covid-19 pandemic, the public hearing will be taking place remotely, using Microsoft Teams.

The independent panel members are:

Chair: Mr Nigel Pascoe QC
Panel members: Dr Mike Durkin
Prof Hilary McCallion
Ms Priscilla McGuire

Terms of reference

In line with the Terms of Reference for the public hearing process, the Panel will focus on five key policy areas:

Reviewing the need for a new independent investigative process
The handling of complaints
Communication and liaison with families
Action plans
Supervision by West Hampshire CCG of those issues.

The independent Panel will consider whether the current policies are appropriate or if they require improvement and if so, it will make recommendations. The Panel will also consider the extent to which the Trust has implemented recommendations from previous reviews and investigations and where further improvements can be made.

A report will be produced by the independent Panel once the hearing has concluded.

Hearing participants

The independent Panel has invited service users of Southern Health NHS Foundation Trust to provide information to the Panel to assist with its investigation of the above issues.

Information will also be provided by the Trust and the Clinical Commissioning Group (CCG).

Joining the hearings

If you wish to view the public sessions , you will need to email the Panel Secretary in advance to request a link for each day (before 10:00am each day). The link must not be shared with anyone else.

A schedule of sessions for week commencing 26 April is available here.

The Panel Secretary can be contacted at: a.scott@pumpcourtchambers.com

If you have any questions, please email the Panel Secretary, Alice Scott: a.scott@pumpcourtchambers.com.

Please notify the Panel Secretary of any access issues.

Easy-read information about the stage 2 review

An easy-read explanation of the stage 2 process and how to join it is available below for any interested services users

Data Privacy Notice

Please see our data privacy notice and the Terms of Reference for the hearings, explaining how we will use and store your data, in accordance with data protection law. These can also be requested from the Panel Secretary.

Invitation to service users to participate in the hearings (now closed)

The Panel will be interested to hear from service users of Southern Health NHS Foundation Trust who have had relevant experience of these specific policy issues.

However, the Panel will not look into any individual, specific cases or facts arising from your contribution.

If you are interested in providing information to the Panel to consider, please note the following steps:

By 10am on Thursday 11 February 2021 you must have registered your interest by emailing the Panel Secretary, Alice Scott at: a.scott@pumpcourtchambers.com. Then you will be asked to sign a consent form and sent a link to a secure online portal to submit to the Panel a 500-word maximum initial statement, limited to one or more of the policy issues identified, and any relevant documents.

By Friday 12 February 2021, if you submitted a statement as above, you will be informed by the Panel Secretary if the Panel require a further, more detailed written statement from you and you will be sent a link to upload it to the online portal.

By 4pm on Monday 22 February 2021, you must have uploaded your further statement and any relevant documents to the online portal.

If these deadlines are not met, then your evidence will not be considered by the Panel.

The Panel will then decide whether to invite you to give oral evidence and you will be informed of their decision on Friday 26 February 2021

Stage 1 Report into Southern Health NHS Foundation Trust: February 2020

On behalf of NHS Improvement, Mr Nigel Pascoe QC conducted an independent review of the investigations into the deaths of four patients under the care of Southern Health NHS Foundation Trust between 2011-2015. Please note and observe the associated data and confidentiality notice when reviewing the report.

Independent Inquiries and Reviews

An independent inquiry into the care and treatment of Mr CD: January 2020

This is a report of the independent investigation into the care and treatment of Mr CD who was convicted of murder on 8 March 2016. Mr CD had received mental health and substance misuse services provided by Southern Health NHS Foundation Trust (SHFT) on several occasions between 2011 and September 2014. On the day of the homicide (20 March 2015) Mr CD had received substance misuse services provided by Solent NHS Trust.

An independent inquiry into the care and treatment of JK: December 2016

This is the report of the independent investigation into the care and treatment of JK who was convicted of murder and was given a life sentence with a 20 year tariff. At the time of the homicide (June 2014), JK was receiving mental health services provided by Southern Health NHS Foundation Trust.

This is the assurance report commissioned by NHS England of the Southern Health NHS Foundation Trust Action Plan following the independent investigation into the care and treatment of JK.

Mazars – independent review – Southern Health NHS Foundation Trust: December 2015

The preventable death of Connor Sparrowhawk in July 2013 led to a number of investigations and enquiries into practice at Southern Health NHS Foundation Trust in whose care he died.

At the request of Connor’s family, NHS England South commissioned the firm Mazars to undertake an independent investigation of the deaths of all patients of Southern Health who had been in receipt of mental health or learning disability services between April 2011 and March 2015.

Reports

Oversight briefings

The oversight group provides ongoing monitoring and assurance around the delivery of learning disability services by Southern Health NHS Foundation Trust.

Independent review into issues that may have contributed to the preventable death of Connor Sparrowhawk: October 2015

Connor Sparrowhawk died in July 2013 while he was in the care of Southern Health NHS Foundation Trust. An independent report concluded that Connor’s death was preventable and that there were significant failings in his care and treatment.

Following publication of this report in February 2014, Oxfordshire Safeguarding Adults Board and NHS England (South) commissioned a second report in June 2014 to find out whether there were wider commissioning, leadership or management issues that could have contributed to the inadequate care that Connor received.

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