‘A failure of leadership’: official report’s verdict on NHS trust’s scrutiny of deaths

NHS England commissioned report finds Southern Health investigated 'too few' mental health or learning disability deaths

An independent report commissioned by NHS England has heavily criticised Southern Health NHS Foundation Trust for investigating “too few” deaths of people with learning disabilities or mental health conditions.

A version of the report, by audit firm Mazars, leaked last week. Today’s official publication revised some figures from the leaked version, which had been heavily contested by the trust. However, it maintained the verdict that the trust’s senior management and board failed to make sure deaths were properly looked into.

The report identified 10,306 deaths that took place over a four-year period. Just 1% of all deaths of learning disability patients were investigated, compared to 30% of adult mental health patients.

Among older adults with mental health conditions only 0.3% of deaths were investigated.

The report said it was not possible to say exactly how many deaths should have been investigated because national guidance on reporting was open to discretion from trusts.

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, the report found.

Almost two-thirds of investigations failed to involve families, it added.

‘Inadequate’ scrutiny

A section from the easy read version of the report

A section from the easy read version of the report

The review warned inadequate scrutiny by the trust’s board and senior management meant opportunities for learning were missed and families had a lack of assurance that relatives’ deaths were unavoidable.

The report authors acknowledged Southern Health had made some improvements in recent months, but concluded: “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.”

Today the government and NHS England responded to the report:

  • Health secretary, Jeremy Hunt announced that the Care Quality Commission will inspect Southern Health on the way it investigates patient deaths.
  • Hunt said the CQC would also carry out a wider review into the investigation of deaths across all types of NHS trust.
  • NHS England said it had referred the Mazars review to health regulator Monitor to consider taking regulatory action against the trust.


The Mazars review 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’ but later conceded it could have been prevented. An inquest in October found neglect contributed to Connor’s death.

Connor’s family said the Mazars findings marked “a very dark moment in the history of the NHS” and called for immediate changes to Southern Health’s leadership.

Katrina Percy, the trust’s chief executive, said: “We fully accept that our processes for reporting and investigating deaths of people with learning disabilities and mental health needs were not always as good as they should have been. We also fully acknowledge that this will have caused additional pain and distress to families and carers already coping with the loss of a loved one.

“We apologise unreservedly for this and recognise that we need to make further improvements.”

She added that the report’s lessons applied to the “wider health and social care system” and claimed that in most cases considered by Mazars, Southern Health was not the main care provider.

The report was originally due to be published in Autumn but was delayed as Southern Health contested the findings.

Connor’s mother, Dr Sara Ryan, said the process had been “tortuous”.

“This review, and the process leading to its publication, clearly and simply demonstrate the lack of value attributed to certain people’s lives (and deaths). This is beyond saddening and a foul indictment of the way in which health and social care practices operate.

“The CEO and board of Southern Health should stand down immediately and an immediate investigation launched into the extent to which these practices are replicated across the UK.”

Jane Cummings, Chief Nursing Officer at NHS England, said: “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 demands 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.”

One leading learning disability expert said the responses announced by the government and NHS England didn’t go far enough.

Equal rights and discrimination

In a blog post, Rob Greig, chief executive of the National Development Team for Inclusion and a former national director for learning disabilities, said firmer action was needed.

“Why has Jeremy Hunt announced there will be a CQC investigation? How many investigations and reports do we need (Mazars is not the first one) before something is done to change how people with learning disabilities and their families are experiencing some parts of the NHS (and older people, and people with mental health problems)?” he wrote.

On the differences observed by Mazars in the levels of deaths investigated within different patient groups, Greig said: “The only plausible explanation for this is a belief that the lives of people with learning disabilities and of older people are less important than those of others.

“This may have been driven by a belief that non-investigation of those deaths was less likely to be challenged, or possibly by a cruder lack of value given to the people themselves. Either way, we are talking about equal rights and discrimination.”

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