Southern Health NHS Foundation Trust will receive expert support to improve the way it investigates and reports deaths at the trust, particularly among people with a learning disability and/or those who are experiencing mental illness, health sector regulator Monitor has announced.

Monitor has made this move in the wake of a critical report into Southern Health by Mazars, published in December 2015, which found, among other failings, that the trust failed to adequately investigate unexplained deaths. In addition, Mazars found that 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 and there was a lack of family involvement in investigations after a death. 

Monitor has taken regulatory action and agreed a number of steps with the trust to ensure these issues are addressed as quickly as possible. 

The trust has agreed to implement the recommendations of Mazars’ report, and to get expert assurance on how well it plans and carries out those improvements. Monitor will appoint an improvement director for the trust, who will use their expertise to support and challenge the trust as it fixes its problems. 

Claudia Griffith, regional director for Monitor, said: “The NHS should take every opportunity to learn from any mistakes that happen when caring for people, to ensure that they are never repeated again.

“We have taken action to ensure that Southern Health improves the way it investigates deaths among people with a learning disability and/or those who are experiencing mental illness.

“However, it is also clear that more work is needed across the NHS to identify and spread best practice for reporting and investigating deaths among people with a learning disability and/or mental illness.”

Monitor will work closely with the Care Quality Commission (CQC) to assess how deaths among people with a learning disability and/or mental illness are investigated and what further action is needed across the NHS and by the trust.

However, Jan Tregelles, chief executive of Mencap, said the move does not go far enough: “The Mazars’ review showed that Southern Health only investigated 4 out of 93 unexpected deaths of people with a learning disability. This meant that opportunities were missed to learn from these deaths. Families are clear that those responsible for this failure must be held to account. Monitor’s announcement today will not address this concern. It offers little in the way of accountability of Southern Health leadership and it is not clear how families will get answers about what happened to their loved ones. 

“Monitor and CQC have announced an investigation into how deaths of people with a learning disability are investigated across the NHS. They must set out a timetable for completing this and what it will cover, given concerns that the issues exposed at Southern Health may also be present in other parts of the NHS.”