The Care Quality Commission has identified “serious concerns” about the safety of mental health and learning disability patients at Southern Health NHS Trust.
An inspection report published today said the trust’s leadership was “ineffective” in identifying and addressing risks to patients, including those posed by ligature points.
The need to spot and act on risks was also “not driving the senior management or board agenda”, the report found. The trust’s leaders were not proactive in tackling issues and too often only acted once CQC had “repeatedly” raised concerns, it added.
The CQC visited the trust in January as part of a focused inspection. The findings led the regulator to issue a warning notice requiring Southern Health to take immediate action to ensure the safety of patients at two of its units.
Yesterday afternoon Mike Petter, the trust’s chair, announced his resignation. The trust’s chief executive is facing calls to step down.
The CQC inspection was ordered by health secretary Jeremy Hunt after the publication of a report by audit-firm Mazars, which found Southern Health investigated “too few” deaths of mental health and learning disability patients. The Mazars review, published in December, blamed a “failure of leadership”.
The CQC assessed Southern Health’s governance arrangements and its progress in making improvements in response to the Mazars findings. The CQC found:
- Effective arrangements had not been put in place to identify, record or respond to concerns about patient safety raised by patients, their carers, staff or by the CQC.
- The trust had also failed to identify, record or respond effectively to staff who expressed concerns about their competence to carry out their roles.
- Even though concerns relating to ligature risks in acute inpatient mental health and learning disabilities services had been identified by CQC in January 2014, October 2014 and August 2015, the trust had failed to sufficiently address these.
- The trust’s arrangements for investigating patient safety incidents were not robust and led to “missed opportunities” for learning.
Concerns about leadership
Dr Paul Lelliott, the CQC’s lead inspector for mental health, said: “We found that in spite of the best efforts of the staff, the key risks and actions to address them were not driving the senior leadership or board agenda.
“I am concerned that the leadership of this trust shows little evidence of being proactive in identifying risk to the people it cares for or of taking action to address that risk before concerns are raised by external bodies. Along with partners including NHS Improvement and NHS England, we will be monitoring progress extremely closely.”
The CQC did identify some improvements at the trust. Acutely unwell people in the community were better supported and the environments in children’s mental health services and forensic services had improved.
Lelliott acknowledged the trust had also introduced a new system for reporting and investigating safety incidents, including deaths, since the Mazars review but said it was “too early to gauge the effectiveness of the new process”.
Katrina Percy, Southern Health’s chief executive, said the CQC findings sent “a clear message to the leadership of the trust that more improvements must be delivered and as rapidly as possible”.
“We fully accept that until we address all these concerns and our new reporting and investigating procedures introduced in December 2015 are completely effective, we will remain, rightly, under intense scrutiny,” she said.
The Mazars review into Southern Health was commissioned by NHS England in response to the death of 18-year-old Connor Sparrowhawk in July 2013.
Connor, who had learning disabilities and autism, drowned in the bath at a Southern Health unit after an epileptic seizure. The trust initially attributed his death to ‘natural causes’ but later conceded it could have been prevented. An inquest found neglect contributed to Connor’s death.
Call for resignations
Today’s CQC report found a specific ‘protocol for the safe bathing and showering of people with epilepsy’ had still to be approved by the Southern Health board more than two and a half years after Connor’s death.
“This patient had drowned while bathing, unobserved by staff, after having an epileptic seizure. We noted that the new protocol had been made available on the trust’s intranet from 1 February 2016 and was ‘signed off’ by the board during our inspection,” the CQC said.
Sara Ryan, Connor’s mother, said the CQC’s findings were “shocking but not surprising”. She called for Percy, and the trust’s board, to resign.
“This report underlines that they do not know what they’re doing and they cannot improve. They only make changes when it seems they’re pinned against the wall and have no other option, so they need to resign for a start,” she said.
Ryan said she and others involved in the grassroots ‘Justice for LB’ campaign (Connor’s nickname was laughing boy or LB) would also continue to push for progress on wider issues in the way people with learning disabilities are treated.
“The deaths that have already happened at Southern Health need to be investigated properly. There also needs to be better scrutiny of these deaths across all the health trusts and a change in the assumption in health and social care that certain people just die early.”