Health Secretary Jeremy Hunt expressed the government’s shock at the alleged failings at Southern Health NHS Foundation Trust – where more than 1,000 unexpected deaths were not investigated between 2011 and 2015 – but has stopped short of calling for a public inquiry into the trust.
In response to an urgent question from Labour’s shadow health minister, Heidi Alexander, on Mazars’ draft report into Southern Health, Hunt said it was “totally and utterly unacceptable that, according to the leaked report, only 1% of the unexpected deaths of patients with learning disabilities were investigated.”
However, when Liberal Democrat MP and former Care Minister, Norman Lamb, asked if he would consider a public inquiry into the treatment of people with learning disabilities, or those with severe and enduring mental ill health, “who too often continue to be treated as second-class citizens in our NHS?” Hunt stopped short.
Sara Ryan, mother of Connor Sparrowhawk, who died of an avoidable cause in an assessment and treatment unit run by Southern Health, and was the driving force behind getting the Mazars report commissioned, has previously called for a public inquiry.
“I am happy to consider that,” he said. “My only hesitation is that a public inquiry will take two, three or four years, and I want to ensure that we take action now. I hope I can reassure him and the House that by, for example, publishing Ofsted-style ratings for the quality of care for people with learning disabilities across every clinical commissioning group, we will shine a spotlight on poor care in the way that the Francis report tells us that we must.”
Hunt added that he believes that Mazars’ report, the final version of which he expects to be published before Christmas, will: “lead to important changes.”
He said: “The fundamental question on which we all need to reflect is why we do not have the right reporting culture in the NHS when it comes to unexpected deaths. We have to step back, be honest and say that there are reasons, good and bad, for that. People are extremely busy, and there is a huge amount of pressure on the frontline. People have an understandable desire to spend clinical time dealing with the patients who are standing in front of them, rather than going over medical notes and trying to understand something that went wrong. Sometimes, there will be prejudice and discrimination. The whole House will unite in saying that we must stamp that out. Sometimes, people do not speak out because they are worried that they will be fired or penalised. We have to move away from a blame culture in the NHS to a culture in which doctors and nurses are supported if they speak out, which too often is not the case.
“The whole House will want to unite in supporting the leaders of the NHS who want to change that culture. It is unfinished business from Mid Staffordshire NHS Foundation Trust; it is important to get it right, and I know that the NHS is determined to do just that.”
Hunt also paid tribute and offered an apology to Sara Ryan: “Her determination to make sure the right lessons are learned from Connor’s unexpected and wholly preventable, tragic death is an inspiration to us all,” he said. “Today, I would like to offer her and all other families affected by similar tragedies a heartfelt apology on behalf of the government and the NHS.”
But Jan Tregelles, chief executive of Mencap, has called on Hunt to go further: “Jeremy Hunt has not adequately answered the most important questions put to him in Parliament today – namely how will 1,454 families find out the truth about what happened to their loved ones; what will he do to hold to account those responsible for avoidable deaths and what action will he take to make sure that this scandal of unexpected and avoidable deaths changes attitudes and practice across the health service, so it is never repeated.
“We already know that 1,200 people with a learning disability die avoidably in our NHS each year, and many of the reasons for this have been well known for a number of years from government commissioned research. There is no excuse now not to deliver the radical change needed across health and care services, to end the institutional discrimination faced by people with a learning disability and their families.”