Southern Health NHS Foundation Trust

Debate between Andrew Smith and Suella Braverman

Wednesday 8th June 2016 Westminster Hall

[Suella Fernandes]

I thank my hon. Friend for highlighting the problems communicated to her by families, which echo and reflect the precise concerns about which the families sitting in the Public Gallery feel strongly. They emphasise that this is not an isolated issue. This is something that we all need to take seriously.

The Mazars report is the next chapter in this story. At the request of Connor’s family, NHS England commissioned an independent report into the deaths of people with learning disabilities or mental health problems while under Southern Health’s care. The report reviewed the deaths of people in receipt of care from mental health and learning disability services in the trust between April 2011 and March 2015. The report sought to establish the extent of unexpected deaths in those services and to identify issues that needed further investigation.

The report was published in December 2015, and its main findings included, first, that many investigations into deaths were of “poor quality” and took too long to complete. Secondly:

“There was a lack of leadership, focus and sufficient time spent in the Trust on carefully reporting and investigating…deaths”.

Thirdly, there was a lack of family involvement in investigations after a death and, fourthly, opportunities for the trust to learn and improve were missed.

Of the 1,454 deaths recorded at the trust during the period under investigation, 722 were categorised by the trust as unexpected. Of those, the review looked at 540 and found that only 272 unexpected deaths received a significant investigation. The report did not specify how many investigations there should have been, but it drew attention to the limited number of deaths that were investigated in different categories. The trust has questioned the use of some of those figures, but the picture painted overall was one of inconsistent standards for investigations, raising the worrying prospect that an unspecified number of deaths may not have been investigated properly. The question of whether there may have been other preventable deaths like that of Connor Sparrowhawk could not be definitively answered, which has led to a great deal of concern among the trust’s patients and something of a breakdown in confidence. Understandably, people want to know that they or their loved ones will be safe in the care of Southern Health. Those whose relatives have died while under the trust’s care need reassurance that the investigations were properly conducted and that the deaths were not also the result of avoidable errors.

My constituent Richard West is one of those relatives. His son, David, died in 2013, and he has been seeking answers from the trust ever since. At times, the handling of his case has been very poor indeed. Mr West, a former detective and policeman, says that he was ignored and was even told by a representative of the trust that the deaths of patients in its care were “like an airline losing baggage.” I know from speaking to other families that others have experienced similarly insensitive treatment.

The Mazars report contained serious and specific criticisms of the trust and its management. In particular, it levelled criticism at the board itself for the failures. It found that

“there has been a lack of leadership, focus and sufficient time spent on reporting and investigating unexpected deaths of Mental Health and Learning Disability service users at all levels of the Trust including at the Trust Board.”

[Mr Andrew Smith (Oxford East) (Lab)]

I applaud the hon. Lady on securing this debate and on her excellent speech. In just about any other organisation, such a searing indictment of the board and, by implication, its executives would have resulted in their resigning. Is she surprised that they did not simply stand down and accept responsibility, as they should have?

[Suella Fernandes]

There is a lot of pressure from the public, patients and families for people to step down, and the resignation of the chairman of the board is a reflection of the seriousness with which Southern Health takes this issue.

The report continued:

“Due to a lack of strategic focus relating to mortality and to the relatively small numbers of deaths in comparison with total reported safety incidents this has resulted in deaths having little prominence at Board level… There are a number of facets to this poor leadership…: a failure to consistently improve the quality of investigations and of the subsequent reports; a lack of Board challenge to the systems and processes around the investigation of deaths…; a lack of a consistent corporate focus on death reflected in Board reports which are inconsistent over time and which centre only on a small part of the available data; an ad hoc and inadequate approach to involving families and carers in investigations; a lack of focus on deaths amongst the health and social care services caring for people with a Learning Disability; limited information presented at Board and sub-committee level relating to deaths in these groups…; and a lack of attention to key performance indicators…indicating considerable delays in completing…investigations.”

The report also found:

“There was no effective systematic management and oversight in reporting deaths and the investigations that follow… The Trust could not demonstrate a comprehensive, systematic approach to learning from deaths”.

In what I consider one of its most damning findings, the Mazars report also found evidence of repeated warnings being ignored:

“Despite the Board being informed on a number of occasions, including in representation from Coroners, that the quality of the…reporting…and standard of investigation was inadequate no effective action was taken to improve investigations”.

The report also stated:

“Despite the Trust having comprehensive data relating to deaths of its service users it has failed to use it effectively to understand mortality and issues relating to deaths of its Mental Health or Learning Disability service users.”

By any measure, those criticisms were immensely serious and required a robust response.

Following the report’s publication, my right hon. Friend the Secretary of State for Health expressed his determination to learn the lessons of the report and set out a number of measures to address the issues raised, including a focused inspection by the Care Quality Commission looking in particular at the trust’s approach to the investigation of deaths. As part of that inspection, the CQC was asked to assess the trust’s progress on implementing the action plan required by NHS Improvement and on making the improvements required by its last inspection, published in February 2015. Separately, the CQC was also asked to undertake a wider review of the investigation of deaths in a sample of all types of NHS trusts in different parts of the country. That is particularly important because we need to know whether the problems and failings at Southern Health are exceptional outliers or whether there is a similar problem in other parts of the country.

The trust accepted the findings of the Mazars report and apologised unreservedly for the failings identified. NHS Improvement set out in January 2016 its plans to provide assistance to the trust to ensure that it delivers on plans to implement the agreed improvements, which include the appointment of a new improvement director and the taking of advice from independent experts. All those measures were agreed by the trust’s management, and in January we had a letter from the chief executive officer setting that out.