CQC logoThe Care Quality Commission (CQC) has reported serious concerns about the safety of patients with mental health problems and learning disabilities in some locations operated by Southern Health NHS Foundation Trust – despite it being warned to improve.

The CQC’s short-notice, focused inspection of Southern Health NHS Foundation Trust, conducted over four days in January 2016, found that many of the previously reported failings – especially in relation to governance, patient safety and ability to respond to patient concerns – were still evident. 

In addition, the board of Southern Health were criticised for showing 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.

This CQC’s inspection took place following the publication the independent Mazars report in December 2015, which described a number of serious concerns about the way the Trust reported and investigated deaths, particularly of people using its mental health and learning disabilities services. It also identified that the Trust had failed to consistently and properly engage families in investigations into the death of their relatives.

In response, Health Secretary Jeremy Hunt requested that CQC review Southern Health’s governance arrangements and approach to identifying, reporting, monitoring, investigating and learning from deaths, and the trust’s progress in implementing the action plan required by Monitor (now NHS Improvement) to address this.

In addition, CQC wanted to check whether the Trust had made the improvements required as a result of its previous comprehensive inspection in October 2014 and the focused inspection of the learning disability services at the Ridgeway Centre, High Wycombe carried out in August 2015.

The CQC’s team of 22 inspectors, which included several mental health professionals as specialist advisors spoke with patients, carers, staff, the trust board and whistle blowers. In addition, they reviewed patient records, serious incident reports, medication charts and policy and procedures including those relating to complaints and governance. They found that:

The trust had not put in place robust governance arrangements to investigate incidents, including deaths. As a result, opportunities had been missed to learn from these incidents and to take action to reduce the likelihood of similar events happening in the future

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

Inspectors had serious concerns about the safety of patients with mental health problems and learning disabilities in some of the locations inspected. Action had not been taken to address known risks from the physical environment. For example, CQC had identified concerns relating to ligature risks in acute inpatient mental health and learning disabilities services in January 2014, October 2014 and August 2015. During the January 2016 inspection CQC found that the trust had still failed to make sufficient changes to address these risks with many potential ligature anchor points identified at one location. Immediately following the inspection, CQC issued a warning notice requiring Trust to take immediate action to ensure the safety of patients at Evenlode, Oxfordshire and Kingsley ward at Melbury Lodge

Overall, the Trust’s governance arrangements did not facilitate effective, proactive, timely management of risk. Where action was taken by the Trust to mitigate risk, this was delayed and mainly done in response to concerns raised by the CQC.

Dr Paul Lelliott, deputy chief inspector of hospitals and lead for mental health, was critical of the trust: “Since the failings identified in the Mazars report, this trust has, rightly, been under intense scrutiny. In December 2015 it introduced a new system for reporting and investigating incidents, including deaths. It is too early to gauge the effectiveness of the new process. However, our inspectors found that the quality of the incident reports and initial management assessments conducted both before and after the introduction of the new procedures, varied considerably.

“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. It is clear that the trust had still missed opportunities to learn from adverse incidents and to take action to reduce the chance of similar events happening in the future. 

“For example, although the Trust had identified that when people did not attend appointments, they could be at high risk of harm, there was no clear guidance for staff working in community mental health teams about what they should do when a patient does not attend an appointment.

“While all clinical staff had been informed of the new system for reporting incidents and patient deaths, we found on our inspection in January 2016 that some staff were still unsure of when and how to involve families, and it was not always clear what discussions or communications had taken place to involve families.

“We were also very concerned about the lack of action taken to address risk to people posed by the physical environment in which they were being cared for. For example, we asked the trust to take immediate action to ensure patients who access the garden at Melbury Lodge do not climb onto the low roof. There have been a number of incidents of patients injuring themselves, some seriously, by falling from the roof, and of patients detained under the Mental Health Act absconding by that route. We issued a warning notice immediately following this inspection requiring the Trust that they must make improvements to ensure people’s safety.  We also told the Trust that they must put in place effective governance arrangements to ensure that patient safety incidents are investigated and learned from.

“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. We will be looking not only for evidence of improvements, but for evidence that this Board is actively planning to protect patients in their care from the risk of harm.” 

Southern Health has an action plan setting out the steps it will take to address the concerns identified in the warning notice and CQC has said it will be monitoring the trust closely with regards to its progress. A further inspection will take place in due course to check that the required improvements have been made and are being sustained.

National scandal

Sara Ryan, mother of Connor Sparrowhawk, whose death in an assessment and treatment unit run by Southern Health was contributed to by neglect – and was the trigger for the Mazars report – branded the continued failings at Southern Health “a national scandal.”

Speaking to the BBC, Ryan said: “It [the CQC’s report] shows that certain people in our society aren't given the same healthcare treatment as other people. 

"How much more failing do we have to have evidence for before the chief executive and the rest of the board are removed?"

Clear message

In response, Katrina Percy, chief executive of Southern Health, said: “Today's CQC report sends a clear message to the leadership of the trust that more improvements must be delivered and as rapidly as possible. I want to reassure our patients, their families and carers that I am absolutely focused on addressing the CQC's concerns and supporting our staff to provide the best care possible.

“As well as rightly highlighting areas of concern, I am pleased that the CQC recognises our staff's caring attitude to patients and the progress made in a number of units, including one of our community mental health teams our mental health inpatient units and our child and adolescent mental health services. This progress reflects the unwavering dedication of our staff, and my job is to make sure these improvements are now carried through consistently across all our services.

“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. We will continue to share regular updates on progress publicly to demonstrate improvement and help re-build trust in our services.”

In addition, Mike Petter, chair of Southern Health, has resigned. “The trust has recently undergone a significant amount of scrutiny in some service areas and given the challenges it faces I feel it is appropriate for me to allow new Board leadership to take forward the improvements,” he said.

Wider problem

Meanwhile learning disability charity Mencap has said that the troubles at Southern Health are indicative of a wider problem around the inadequate healthcare experienced by people with a learning disability in the NHS.

Dan Scorer, head of policy at Mencap, said: “The [CQC] report highlights the trust’s continual failure to address the regulator’s concerns. In particular, there has been no pro-active response to previous CQC warnings around the safety of patients with a learning disability and amongst staff there remains confusion over when and how to involve families in their loved ones’ care.

“This report by the CQC comes 5 months after the Mazars report… [which] said that where deaths were investigated the Trust didn't adequately involve families, investigations were of poor quality, took too long to complete, and lacked relevant learning from the deaths that took place. This CQC report shows disturbingly little action taken to address these failings.

“However, this problem is far wider. Since 2011, NHS mental health trusts in England have investigated just 222 out of 1,638 deaths of patients with a learning disability. While just 35% of the 397 deaths which were classed unexpected have been investigated.

“Many families are being left with fundamental questions about why their loved one died, whether there should have been an investigation, and whether their death could have been avoided.  The lack of urgency to tackle this national scandal is unacceptable. The government and the NHS must ensure there are investigations into all unexpected deaths of people with a learning disability and that the outcomes of these lead to real change.”