In October an inquest jury found neglect contributed to the death of 18-year-old Connor Sparrowhawk at a Southern Health NHS Trust learning disabilities unit.
Standing outside the coroner’s court, Connor’s mother, Sara Ryan, and stepfather, Richard Huggins, were told Southern Health had issued an apology.
“Have they?” came the reply. “To who? They’ve not said anything to us.”
The trust had made sure to tell journalists they were sorry. They just hadn’t told those that needed to hear it most.
Southern Health got its priorities wrong then and it did so again last week in the way it responded to a leaked report ordered by NHS England after Connor’s death.
The report, by audit firm Mazars, accused Southern Health of investigating just 1% of deaths of people with learning disabilities and 0.3% of deaths among over 65s with mental health conditions.
A lack of leadership
Southern Health contests those figures and has spent much time and effort making sure people know it. Yet the trust has said far less about a series of failings in leadership, governance and family involvement flagged up by the Mazars review.
These include concerns the trust’s senior management placed too little focus on making sure deaths among these patient groups were properly looked into. That the trust failed to act properly on warnings from coroners over the quality of investigations. That the board was too quick to accept reassurance from senior management that everything was in order. And that the trust’s culture meant there was a lack of openness when things went wrong.
And families? Families were apparently left out of almost two-thirds of investigations which were carried out. When people with a learning disability died, involvement of their families was “negligible”. Some of the trust’s written reports also used the wrong names for the deceased, something Mazars said would have caused “further distress” to those who lost loved ones if they’d known about it.
Last week, after the report leaked, Southern Health’s chief executive, Katrina Percy, was asked if the trust had let down patients and families. She apologised to anyone “who feels let down” – a very different apology to acknowledging people were let down. She has refused to resign.
It is right that Southern Health can challenge the Mazars findings. It is also the case that they’ve had the opportunity to do so for months. In whose interests is it that the report, due to be published in the autumn, is still not in the public domain?
Staff and service user wellbeing
The trust say they are contesting the findings primarily out of concern for patients. A briefing Southern produced for NHS England, prior to the leak, said inaccurate findings could impact the wellbeing of patients and staff.
The wellbeing of patients and staff at Southern Health has come up before. Back in February, the Care Quality Commission’s inspection report found some of Southern’s staff and service users were concerned at a lack of openness and honesty in the trust’s response to Connor Sparrowhawk’s death.
The report said: “This was clearly causing distress and affecting staff morale and unrest with people using services and their families. They felt the trust had failed to communicate effectively and was acting outside of its own values”.
NHS England will publish the Mazars review before Christmas, possibly this week. When it does, Southern Health will again have to respond and consider what matters most here.
The trust could take a cue from the way some of its own frontline staff handled Connor’s inquest. Over the two weeks of evidence sessions, some of the staff involved in Connor’s care took the opportunity to apologise to his family. Not through a statement issued to media, but by looking them in the eye and saying sorry.
Connor’s family later said how grateful they were for those “heartfelt apologies” from staff. It meant a lot that people had taken responsibility. In contrast, the trust’s response left them feeling that the organisation’s leaders were “focusing more on their reputation” than the distress caused to families.
With its responses to the Mazars review so far, Southern is making the same mistake.