Southern Healthcare NHS Foundation Trust failed to investigate more than 1,400 unexpected deaths – many of whom were of people with mental ill health or learning disabilities – between 2011 and 2015, according to a leaked report.

The draft report, commissioned by NHS England and carried out by auditing firm Mazars, and seen by the BBC, found 10,306 people had died at the trust between April 2011 and March 2015 and of those, 1,454 were unexpected – meaning that the person died earlier than they would have been expected to.

Of those 1,454, only 272 were treated as critical incidents, of which only 13% were treated by the trust as a serious incident requiring investigation.

Mazars’ report also found that the likelihood of an unexplained death of a person with learning disabilities being investigated was just 1%. Meanwhile, 30% of cases involving adults with mental health problems were investigated, although this dropped to just 0.3% for over-65s with mental ill health. 

Almost two-thirds of the serious incident investigations did not involve the family of the deceased, with the failings worst in learning disability services. In addition, the average age at death of those with a learning disability was just 56 – more than seven years younger than the national average, which in itself is more than a decade younger than the general population. 

Mazars also found that even when investigations were carried out, they were not of a good quality – including some basic errors, such as using the wrong name of the deceased – and often very late. 

Some initial reviews of deaths were carried out before a decision had been made to investigate them or not, and these were undertaken by the staff who were under scrutiny. In one case, a care coordinator reviewed their own care as ‘good’ and said that no further review was necessary.

The report laid the blame for the failures with Southern Health’s senior executives and its trust board, saying there was no "effective focus or leadership from the board.” 

According to the BBC, the report said that even when the board did ask relevant questions, they were constantly reassured by executives that processes were robust and investigations thorough. However, the Mazars investigators said this was contrary to their findings.

The report went onto damn the culture in Southern Health, which it said: "results in lost learning, a lack of transparency when care problems occur, as well as lack of assurance to families that a death was not avoidable and has been properly investigated.”

The report is the culmination of two years’ work. It was commissioned in 2013 after the death of 18-year-old Connor Sparrowhawk – also known as ‘Laughing Boy’ or ‘LB’ – who drowned in a bath at a Southern Health assessment and treatment unit in Oxfordshire after an epileptic seizure.

Earlier this year, an inquest jury found that neglect had contributed to his death and noted several other serious failings in his care at the unit.

Speaking to the BBC, Connor's mother, Sara Ryan, said the entire leadership of Southern Health had to go. "There is no reason why in 2015 a report like this should come out,” she said. “It's a total scandal. It just sickens me."

In response, Southern Health issued a statement saying the trust had “serious concerns” about the draft report’s interpretation of the evidence.

“We fully accept that our reporting processes following a patient death have not always been good enough,” the statement continued. “We have taken considerable measures to strengthen our investigation and learning from deaths including increased monitoring and scrutiny.

“The review has not assessed the quality of care provided by the Trust. Instead it looked at the way in which the Trust recorded and investigated deaths of people with whom we had one or more contacts in the preceding 12 months. In almost all cases referred to in the report, the Trust was not the main provider of care.

“We would stress the draft report contains no evidence of more deaths than expected in the last four years of people with mental health needs or learning disabilities for the size and age of the population we serve.

“When the final report is published by NHS England we will review the recommendations and make any further changes necessary to ensure the processes through which we report, investigate and learn from deaths are of the highest possible standard.”

Mazars was contacted for comment, but said that it is not releasing a statement at this time as the report has not been finalised. However, a final version will be published “as soon as possible.”

Concern at findings

Luciana Berger MP, Labour's Shadow Minister for Mental Health, called for action from the government over this report. “For there to have been so many unexpected deaths in one Trust is of deep concern itself, but for so many of those deaths not to have been investigated is extremely alarming,” she said. “It raises serious questions about the leadership and culture of care at the Trust. 

“We urgently need answers. Ministers must take action to understand how this was allowed to happen and answer important questions about whether or not these services are now safe.”

Learning disability and autism charities have also reacted with concern to the report’s findings. Mark Lever, chief executive of the National Autistic Society, said: "While we need to wait for the final version to be sure of the facts in these cases, we are deeply concerned about these findings. In all cases, there should be close scrutiny of unexpected deaths, as we would expect for anyone dying outside these institutions. Whether an investigation takes place after a death or not should not depend on someone’s disability or age – they should be standard. 

“Urgent action is clearly needed, locally and nationally, to make sure that people with learning disabilities, autism and mental health problems receive high quality and safe care and that all unexpected deaths are investigated thoroughly. NHS England must publish the full report as soon as possible so this vital work can get under way.”

Jan Tregelles, chief executive of Mencap, added: “One of the key recommendations of the government commissioned ‘Confidential Inquiry into premature deaths of people with learning disability’ was the importance of proper analysis into the deaths of people with a learning disability.  Only then we will be able to identify the causes of avoidable deaths and ensure that they are properly addressed. 

“Mencap’s Death By Indifference campaign has highlighted the lack of value and lack of priority placed on the lives of people with a learning disability. This is a very real crisis that is happening to people with a learning disability and their families across the UK right now. When the final report is published we will be looking very carefully at the recommendations, as we remain extremely concerned about the lack of progress on this issue by government and the NHS.”

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