CQC logoSouthern Health NHS Foundation Trust must make significant improvements to protect patients in its mental health and learning disability services from the risk of harm, health regulator the Care Quality Commission (CQC) has warned.

The CQC issued the warning notice to the Trust, saying it needs to improve its governance arrangements to ensure robust investigation and demonstrable learning following incidents and deaths.

CQC inspectors visited the Trust in January, following the publication of the Mazars report, commissioned by NHS England, which highlighted the failure of the Trust to investigate and learn from the deaths of patients, particularly those receiving care in its older people’s, learning disability and mental health services.

The inspectors also checked on improvements, which had been required in some of the Trust’s mental health and learning disability services, following previous inspections.

Inspectors found that the Trust had failed to mitigate against significant risks posed by some of the physical environments from which it delivered mental health and learning disability services and did not operate effective governance arrangements to ensure robust investigation of incidents, including deaths. It did not adequately ensure it learned from incidents to reduce future risks to patients. In addition, inspectors found that the trust did not effectively respond to concerns about safety raised by patients, their carers and staff, or respond to concerns raised by Trust staff about their ability to carry out their roles effectively.

Dr Paul Lelliott, CQC’s deputy chief inspector of hospitals and lead for mental health, said: “We have made it clear that the safety of patients with mental ill health and or learning disabilities, provided by Southern Health NHS Foundation Trust requires significant improvement.

“We found longstanding risks to patients, arising from the physical environment, that had not been dealt with effectively. The Trust’s internal governance arrangements to learn from serious incidents or investigations were not good enough, meaning that opportunities to minimise further risks to patients were lost.

“It is only now, following our latest inspection, and in response to the warning notice, that the Trust has taken action and has identified further action that it will take to improve safety at Kingsley ward, Melbury Lodge in Buckinghamshire and Evenlode in Oxfordshire. The Trust must also continue to make improvements to its governance arrangements for reporting, monitoring, investigating and learning from incidents and deaths. CQC will be monitoring this Trust very closely and will return to check on improvements and progress in the near future.”

Not addressed serious concerns

Luciana Berger MP, Labour’s Shadow Minister for Mental Health, expressed her concern at Southern Health’s failures: “It is deeply disturbing that Southern Health NHS Foundation Trust has not addressed serious concerns raised about the safety of its patients,” she said.

“It is more than two years since the tragic death of Connor Sparrowhawk, who was in the care of this Trust and a recent report found that Southern Health failed to investigate more than 1,000 unexpected deaths of mental health and learning disability patients since 2011. It is extremely worrying that the Trust’s leadership has not taken the appropriate action to improve patient safety.

“I welcome the steps now being taken by the CQC and NHS Improvement. However, patients and their families will rightly be very concerned about how this situation has been allowed to persist and who is taking responsibility for this fundamental failure of care for some of the most vulnerable people in our society.

“Jeremy Hunt needs to take urgent action to address this situation and provide assurances to patients and families about whether or not these services are currently safe. I intend to raise this with Ministers when Parliament resumes next week.”

In response, Katrina Percy, chief executive of Southern Health, said: “I have been very clear and open that we have a lot of work to do to fully address recent concerns raised about the Trust.

“Good progress has been made, however we accept that the CQC feels that in some areas we have not acted swiftly enough. My main priority is, and always has been, the safety of our patients. We take the CQC’s concerns extremely seriously and have taken a number of further actions. 

“The full CQC inspection report, which we expect to receive later this month, will allow us to consider their findings in full.

“In addition, our regulator NHS Improvement has announced that it intends to take action to allow it to make management changes if progress isn’t made on fixing the concerns raised. NHS Improvement recently appointed an Improvement Director to support us and we are committed to working with him to make the necessary improvements. 

“I want to reassure our patients and their families that I, and the Board, remain completely focused on tackling these concerns as quickly as possible.”

Dan Scorer, head of policy of learning disability charity Mencap, criticised Southern Health for its lack of investigations into unexplained deaths of people with learning disabilities: “The CQC warning notice… comes over 4 months after the Mazars report revealed failings by the Trust in investigating deaths of people with a learning disability. Only 4 out of 93 unexpected deaths of people with a learning disability were found to have been investigated. In addition, Mazars said that where deaths were investigated the Trust didn't adequately involve families, investigations were of poor quality, took too long to complete, and lack relevant learning from the deaths that took place. Today's warning notice from CQC states that little has changed.

“Families are being left questioning whether the death of their loved one should have been investigated and whether the death might have been avoided."

CQC expects to publish a full report of its January inspection of Southern Health in late April.