According to a recent report, the NHS has failed to investigate more than 1,000 deaths since the year 2011.
The report blames a failure in leadership at Southern Health NHS Foundation Trust and says the deaths of patients with learning disabilities and mental illnesses were not examined properly. It was ordered two years ago, after Connor Sparrowhawk drowned in a bath after an epileptic seizure while he was a patient in an Oxford Southern Health hospital, aged 18.
According to an independent investigation, Connor’s death could have been prevented.
Southern Health have said the quality of processes for reporting and investigating deaths have improved, but admitted that it still needs to be better.
As one of the country’s biggest mental health trusts, Southern Health provides services to around 45,000 people and covers Buckinghamshire, Dorset, Hampshire, Oxfordshire and Wiltshire.
The investigation was carried out by large audit firm Mazars and commissioned by NHS England. It studied every death at the trust between April 2011 and March this year. It found that 10,306 people had passed away during that period. Of these, 1,454 were unexpected.
Of the unexpected deaths, 272 were treated as critical incidents, but only 13 percent were treated as an SIRI (serious incident requiring investigation).
The likelihood of an investigation into an unexpected death was largely dependent on the type of patient and the group most likely to see an investigation was adults with mental illnesses. 30% of these underwent investigation.
The figure was 1% for those who had learning disabilities and for people aged over 65 with mental illnesses it was only 0.3%.
For those with learning disabilities, the average age of death was more than seven years younger than the national average, at 56.
The NHS England report states that when investigations took place, they were often extremely late and were of poor quality.
Despite criticisms from coroners about the usefulness and timeliness of inquest reports from Southern Health, performance did not improve and there was often barely any effort to engage with the families of the deceased.
The report says that the reasons for the failures lie with the trust board and senior executives.
It also says that there was no effective leadership or focus from the board, nor was there any effective management of investigations or deaths.
Even when relevant questions were asked by the board, the report states that they were reassured constantly by executives that investigations were thorough and processes were robust. However, the investigators from Mazars said this does not comply with their findings.
The report says that the culture of Southern Health results in a lack of transparency in the occurrence of care problems and lost learning. It also results in lack of assurance to families that a death has been investigated properly and was not avoidable.
Connor’s mother has responded to the findings of the report, saying that a report like this should not come out in 2015 and the entire Southern Health leadership must go.
Authors of the report say they do not have much confidence that the trust has recognised the necessity to improve its investigation and reporting of deaths.