16 December 2015
Poor Leadership to Blame for NHS Trust Investigation Failures
A “failure of leadership” was to blame for the lack of adequate investigations into more than 1,000 unexpected deaths at Southern Health NHS Trust, according to a report by NHS England.
The investigation into Southern Health – one of the largest mental health trusts in the UK, providing services to more than 40,000 people – looked at all patient deaths at the trust between April 2011 and March 2015.
During this time, more than 10,000 patients died. The majority of deaths were expected but 1,454 were not. Of these, 272 were treated as critical incidents and 195 as a ‘serious incident requiring investigation’ (SIRI).
The report found that the likelihood of an unexpected death being investigated largely depended on the type of patient involved. Deaths among those under 65 with mental health problems were revealed as the most likely to be investigated. But only 1 per cent of deaths of patients with learning disabilities and 0.3 per cent of deaths among patients over 65 with mental health problems were properly examined.
Other key findings revealed that despite the Trust having comprehensive data on deaths, it failed to use the information effectively and failed to implement a systematic approach to learning from deaths. In addition, in almost two-thirds of investigations into patient deaths, there was no engagement with bereaved family members or assurances that deaths were not avoidable.
Even when investigations were carried out, they were found to have been substandard and often late. Despite repeated criticism from coroners about the quality and timeliness of reports provided by Southern Health for inquests, both performance and efforts to engage with the families of the deceased failed to improve.
The report concluded that a lack of “effective focus or leadership” from senior executives and the Southern Health NHS Trust board was to blame for the lack of adequate investigations into the deaths of patients with learning disabilities and mental health issues.
The independent report was commissioned in 2013 following the drowning of an 18 year-old patient who suffered an epileptic fit in a bath at a learning disability care unit run by Southern Health.
An investigation found that the man’s death had been preventable while a jury inquest ruled that “serious failings” by the Trust, including poor bathing arrangements, had contributed to his death.
Southern Health said it “fully accepted” that the quality of investigations into deaths needed to be better but that “substantial improvements” had been made since the 2013 tragedy, including mandatory comprehensive epilepsy training for all staff caring for patients with learning disabilities.
Despite this, the authors of the NHS England report said they had “little confidence that the Trust has fully recognised the need for it to improve its reporting and investigation of deaths."
Unfortunately the findings of this report suggest there are still significant on-going concerns regarding social care provision for patients with learning disabilities and mental health issues. Although the recent government spending review allows councils to raise local taxes by an additional, ring-fenced two per cent to help pay for social care services, this does not begin until 2017 and there are currently no details as to how care and support will be funded in the interim.
Limited funding quite simply means reduced care in hospitals and restrictions on the ability of councils to identify and provide services for those most in need. We all remember the appalling abuse suffered by disabled residents at the Winterbourne View unit in Bristol in 2011, and with the estimated £1 billion social care budget cuts on the horizon, it is clearly more important than ever to protect access to essential services for society’s most vulnerable people.
Richard Copson is a senior disability rights lawyer in Slater and Gordon’s Court of Protection team who specialises in Community Care and Mental Capacity Law.
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