Southern Healthcare NHS Foundation Trust has been criticised in a report into its failure to adequately investigate unexplained deaths.

Some of the main findings in the report, compiled by Mazars at the request of NHS England – and which was leaked last week are:

Many investigations were of poor quality and took too long to complete

There was a lack of leadership, focus and sufficient time spent in the Trust on carefully reporting and investigating deaths

There was a lack of family involvement in investigations after a death

Opportunities for the Trust to learn and improve were missed.

A total of 1,454 deaths were recorded at the Trust during this period, with 722 categorised as unexpected by the Trust. Of these, 540 were reviewed and 272 unexpected deaths received a significant investigation. The report does not specify how many investigations there should have been, but draws attention to the limited number of deaths that were investigated in different categories.

The report makes a number of recommendations, including:

The Southern Health board needs to address the culture of lack of review and reporting of unexpected deaths, ensure staff at all levels recognise the need for timely, high quality investigation, how to include families and to ensure learning is demonstrated

There is clear national and trust policy guidance on reporting and investigating deaths. Southern Health’s policy includes a full set of templates and processes – the board should ensure these policies are being followed and templates being used

Unexpected deaths should be defined more clearly. The authors suggest the trust uses, as a starting point, the classification outlined in this report to identify the potential need for review or investigation in each case. In particular, the definition of an ‘unexpected death’ needs to be refined to be more applicable to the circumstances of people with a learning disability regardless of setting.

The trust should develop a Mental Health and Learning Disability Mortality Review Group, which includes reviewing unexpected deaths which do not constitute a serious incident.

NHS England has accepted the findings of the final report, following a period of review which included an independent verification of the methodology used.

Southern Health NHS Foundation Trust and the clinical commissioning groups (CCGs) that commission services from them have also accepted the recommendations.

NHS England has now forwarded the report to Monitor, which will consider as a matter of urgency whether regulatory action is required. The report will also feed into the National Learning Disability Mortality Review Programme, a 3-year project that is the first comprehensive, national review set up to investigate why people with learning disabilities typically die much earlier than average, and to inform a strategy to reduce this inequality.

Jane Cummings, chief nursing officer, said: “Openness, transparency, learning, improving and working with families should be the core tenets of the NHS, especially where things don’t go right.

“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 recommends 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.”

Scandal cannot be ignored

But Southern Health is not alone in its failings, according to Deborah Coles, co-director of specialist advice service INQUEST: “NHS England cannot ignore the scandal that is the failure to properly report and investigate deaths of some of society’s most vulnerable people in the care of the state. Successive governments have been repeatedly warned that the investigation system is not fit for purpose. INQUEST’s casework shows that this is a systemic problem and not isolated to one rogue trust. The public needs to know whether these same failings are replicated elsewhere. This damning report must now prompt a national inquiry into mental health and learning disability deaths. Patients and their families deserve nothing less.

“The disturbing findings of this report were only uncovered because of the tireless fight for the truth by the family of Connor Sparrowhawk and the Justice for LB campaign. What if Connor had no family to speak up on his behalf? Would any of this have come into the public domain?”

Connor’s mother, Dr Sara Ryan, added: “This is a very dark moment in the history of the NHS. The review provides evidence that certain people's lives (and deaths) are discounted in a systematic way with no care or regard. Katrina Percy, and the Southern Health Board, should step down immediately, and the Secretary of State needs to act now to examine the extent to which these findings are replicated in other Trusts across the country.”

Jan Tregelles, chief executive of learning disability charity Mencap, agreed that the lack of reporting is a systemic problem. “Although the government and NHS England have outlined a number of recommendations to ensure that deaths are investigated they have not gone far enough to address the underlying reasons for avoidable deaths of people with a learning disability within the NHS. Previous research by academics has shown that 1,200 people with a learning disability are dying avoidably in the NHS every year and the causes of this are well known.

“A lack of understanding of learning disability and institutional discrimination have continually been mentioned in previous reports and reviews, and the Mazars Review raises similar issues. The government and NHS England must act immediately to address the failures of care that have seen so many people with a learning disability tragically lose their lives within the health system.”

Unreserved apology

In response, Katrina Percy, chief executive of Southern Health, 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.

“In the past, our engagement with families and carers of people who have died in our care has not always been good enough. Whilst we have already made substantial changes in how we approach this, we have more improvements to make.”

Percy added that a number of changes have been made to the way the trust records and investigates deaths, such as strengthening executive oversight of the quality of investigations and ensuring appropriate measures are in place to address any issues identified, and that all learning is shared and implemented across the trust.

In addition, a new central investigation team has been set up, which she said is improving the quality and consistency of investigations and learning, and a new system for reporting and investigating deaths has been launched in consultation with our commissioners to increase monitoring, scrutiny and learning. Finally, every family now has the opportunity to be involved in investigations relating to a death of a loved one.

“We fully accept a need to continue to make changes, and will work with our commissioners and regulatory bodies to make the improvements required,” Percy added. “Our main focus continues to be ensuring that everyone who relies on the services we provide receives the best possible care.

“Reports such as this challenge not only Southern Health, but the wider health and social care system, and society as a whole, to reflect on the way we support, include, and value people with learning disabilities and mental health needs. 

“All providers and commissioners of care can learn from this report. It states that current NHS guidance should be revised to clarify which organisation should lead the investigation into a person’s death when more than one provider is involved in their care. We are keen to contribute to this.”

Percy also defended the trust and its record. “It is important to make clear that the report looked at the way the Trust recorded and investigated deaths of people with mental health needs and learning disabilities who had been in contact with Southern Health staff at least once in the previous year. In most cases referred to in the report, the Trust was not the main care provider.

“The review did not consider the quality of care provided by the trust to the people we serve.

“National data on mortality rates confirms that the Trust is not an outlier. We believe that Southern Health’s rate of investigations into deaths is in line with that of similar NHS organisations.”