Jeremy Hunt criticises NHS trust over response to unexpected deaths [repost]

Jeremy Hunt has criticised a lack of leadership and focus at an NHS trust that allegedly failed to investigate the unexplained deaths of more than 1,000 disabled patients.

The health secretary said an independent investigation into Southern Health NHS Foundation Trust found it had failed to properly examine what could be learned from unexpected deaths of patients with mental health issues or learning disabilities.

The investigation, commissioned by NHS England, was launched after Connor Sparrowhawk, 18, drowned during an epileptic seizure in a bath at Slade House in Headington, Oxfordshire.

The report renewed concerns about institutional discrimination against disabled people, and led to calls for a national inquiry.

In a written statement to the Commons, Hunt echoed concerns about the lack of effective management and oversight of the reporting of deaths and the investigations that follow.

“I am determined that we learn the lessons of this report and use it to help build a culture in which failings in care form the basis for learning for organisations and for the system as a whole,” he said.

The audit firm Mazars examined 10,306 patient deaths that occurred at the trust between April 2011 and March 2015, 1,454 of which were unexpected.

Mazars said there was a “failure of leadership” and a lack of transparency when unexpected deaths occurred. The trust was unable to show it had an effective system in place to learn from such deaths, it reported.

The trust investigated 30% of deaths of adults with mental health problems, 1% of deaths of patients with learning disabilities, and 0.3% of deaths of over-65s with mental health problems.

Patients with a learning disability died at an average age of 56, seven years earlier than the normal life expectancy.

Investigators found that when trust board members did ask questions, executives said they were confident that investigations were thorough, assurances that the auditors said were “contrary to our findings”.

Families of the patients welcomed the review but said they read its conclusions with anger and sadness.

Sue Rawlinson’s daughter Nicki, 26, had a learning disability and died at Barnet hospital in north London in February 2012. “Today’s review is a timely reminder,” she said. “The NHS must start treating the lives of people with a learning disability with the same value as anyone else’s life. It’s an absolute disgrace the way my daughter died.”

Hunt said the Care Quality Commission would undertake a focused inspection of Southern Healthcare early in the new year. The CQC will also undertake a wider review into how deaths are investigated at a range of NHS trusts across the country.

NHS England’s medical director, Bruce Keogh, and its national director of patient safety, Mike Durkin, will write to medical directors of NHS providers offering help with the auditing of avoidable deaths.

Monitor, the NHS regulator, will review the report to consider whether it also needs to take action.

Southern Health cares for about 45,000 people in Hampshire, Dorset, Wiltshire, Oxfordshire and Buckinghamshire.

Katrina Percy, chief executive of the trust, apologised for its failings. “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,” she said.

“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.

“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.”

The trust accepted the need for change, Percy said, including a new system for reporting and investigating deaths which involved the family of the deceased, but said it was not an outlier.

“We believe that Southern Health’s rate of investigations into deaths is in line with that of similar NHS organisations.”

Jan Tregelles, the chief executive of Mencap, said the failings were not just at Southern Health, but a wider problem across the NHS. “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,” she said.

Luciana Berger, shadow minister for mental health, said the findings were appalling.

“It is all the more worrying that this investigation would not have happened were it not for the determination of the families who lost loved ones to seek answers,” she said. “Just because some individuals have less ability to communicate concerns about their care must never mean that any less attention is paid to their treatment or their death.

“Ministers must take urgent steps to improve openness and transparency within our NHS, ensure unexpected deaths are fully investigated and that lessons are learned to prevent future deaths.”