NHS trust investigated ‘too few’ deaths of mental health and learning disability patients

One of England’s largest mental health and learning disability providers failed to investigate the ‘unexpected’ deaths of too many patients, according to a leaked report.

Southern Health NHS Foundation Trust investigated 272 of 1,454 ‘unexpected’ deaths of people with mental health conditions or learning disabilities over a four year period, the report found. It accused the trust of investigating “too few” deaths of older people with mental health problems and people with learning disabilities, where less than 1% of all such deaths were subject to inquiries.

[Update 17/12/15: The official copy of the report has been published. It revised down the figure on ‘unexpected’ deaths to 722, based on the trust’s categorisation. The criticism of the trust for investigating “too few” deaths remained].

The report, a copy of which has been seen by Community Care, blames a “lack of leadership” at the trust. It warns inadequate scrutiny meant opportunities for learning were missed and families had too little assurance that their relatives’ deaths were unavoidable.

When investigations were carried out, they were too often of “poor quality”, severely delayed and, in some cases, had “careless” errors which would distress families.

Responding to the findings, the trust accepted its reporting processes had “not always been good enough” but said it had serious concerns about the way the report, a final draft, interpreted the evidence.

The review was carried out by audit firm Mazars. It was ordered by NHS England after the death of 18-year-old Connor Sparrowhawk in July 2013. Connor, who had learning disabilities and autism, drowned in the bath while a patient at a Southern Health unit. The trust initially attributed his death to ‘natural causes’. It later conceded his death could have been prevented. An inquest in October found neglect contributed to Connor’s death.

‘A total scandal’

Connor’s mother, Sara Ryan, told BBC News that Southern Health’s leadership team should be removed given the findings.

“There is no reason why in 2015 a report like this should come out. It’s a total scandal. It just sickens me,” she said.

Justice campaigners said the findings “should send shockwaves across the NHS” and prompt a national inquiry.

The review warned Southern Health’s culture led to a lack of transparency over failings in care.

It reviewed all deaths at the trust between April 2011 and March 2015. It identified 10,306 deaths, of which 1,454 were considered unexpected. There were 272 deaths treated as ‘critical incidents’, and 195 (13% of all unexpected deaths) given serious incident investigations.

Deaths of working age adult mental health patients were most likely to be scrutinised, with 30% of all deaths investigated. But less than 1% of learning disability deaths and 0.3% of deaths of older people with mental health problems got the same treatment.

‘No effective oversight’

The report authors acknowledged Southern Health had taken some action since April but warned: “We have little confidence that the Trust has fully recognised the need for it to improve its reporting and investigation of deaths of people with a Mental Health (in particular Older People) or Learning Disability need.”

Connor’s family have voiced their anger at Southern Health’s response to his death. The Mazars review paints a damning picture of the way the trust’s senior leadership scrutinised other deaths. The report found:

• A lack of leadership and focus on investigating unexpected deaths existed at “all levels” of the trust, including the board.
• The way the trust presented data on unexpected deaths in its annual report and quality account was “misleading” as only investigated deaths were reported.
• The board failed to act properly on repeated warnings from coroners that the standard of the trust’s investigations was inadequate.
• There was no effective systematic oversight of the way deaths were reported or investigated.
• When written investigations were completed they were often of poor quality and subject to little challenge or rigour.
• Some reports included “careless” errors that would likely distress families. In one case a teenage boy was given three different names. In a second, the wrong name was duplicated because ‘find and replace’ had been used incorrectly.
• Almost two-thirds (64%) of serious incident investigations did not involve the family of patients who died. Family involvement was “negligible” in cases involving learning disability patients.
• The review estimated that in around 4% of cases it was considered inappropriate to contact families, but no involvement was offered in 40% of investigations.

The report said: “There was constant reassurance from executive directors to the board that the [serious incident] reporting process was robust, investigations were thorough and action plans implemented.This is contrary to our findings.”

Deborah Coles, director of the charity Inquest, which has provided support to Connor’s family, said: “This report should send shockwaves across the NHS. The failure to investigate deaths of some of society’s most vulnerable people is a scandal that must be urgently addressed.

“These findings reiterate the need for independent and robust investigations into the deaths of mental health and learning disability patients. What is so disturbing is that this report only came about because of the tireless fight for the truth by the family of Connor Sparrowhawk. This damning report must now prompt a national inquiry. Their families deserve nothing less.”

Trust concerns 

A Southern Health spokesperson 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. We have taken considerable measures to strengthen our investigation and learning from deaths including increased monitoring and scrutiny.

“The review has not assessed the quality of care provided by the trust. Instead it looked at the way in which the trust recorded and investigated deaths of people with whom we had one or more contacts in the preceding 12 months. In almost all cases referred to in the report, the trust was not the main provider of care.”

The spokesperson added: “When the final report is published by NHS England we will review the recommendations and make any further changes necessary to ensure the processes through which we report, investigate and learn from deaths are of the highest possible standard.”

Asked if Connor’s family were reassured by Southern Health’s response to the report, Richard Huggins, Connor’s stepfather, told Community Care: “No. Not at all. It’s not good enough for them to just say ‘we dispute the findings’. The findings are being disputed by those with the most to lose.

“I think NHS England needs to get the report out as soon as possible. But the potential and actual implications of the findings for patients and families, means we need to be totally reassured that the problems raised will be looked at properly. The trust quibbling with the details of some of the data gives little confidence and is a failure of their responsibilities.

“I hope changes are made. I hope things like this stop happening. But it should not take an independent review to produce this evidence and pick these concerns up. I’m not convinced anything will change until there’s a different set of managers and a new board in place. I can’t see how the people in charge of this process for the past three and a half years will make the changes needed. It needs a clean sweep.”

An NHS England spokesperson said: “We commissioned an independent report because it was clear that there are significant concerns. We are determined that, for the sake of past, present and future patients and their families, all the issues should be examined and any lessons clearly identified and acted upon.

“The final full independent report will be published as soon as possible, and all the agencies involved stand ready to take appropriate action.”