Southern Health NHS Foundation Trust

Dan Poulter Excerpts

Wednesday 8th June 2016 Westminster Hall

[Dr Daniel Poulter (Central Suffolk and North Ipswich) (Con)]

I congratulate my hon. Friend on securing this debate, and on her articulate explanation of the issues involved and the tragedies that have befallen a number of patients.

Clearly there has been a failing of clinical governance in the trust on a massive scale. However, I wonder whether my hon. Friend will reflect on two points. First, it is very difficult to deliver improvements in quality in a resource-poor environment, notwithstanding the clinical governance issues, and we know that child and adolescent mental health services and learning disability services have been chronically underfunded for many years nationally.

Secondly, people with learning disabilities often have complex physical healthcare needs as well as mental healthcare needs, and improved staff training needs to be put in place nationally. That needs to be properly resourced and funded if we are to make a meaningful difference and get things right for people in the future.

[Suella Fernandes]

I totally agree with my hon. Friend’s observation. There is a challenge here. This is unfamiliar territory for the NHS, and funding will be necessary to support any new attempt to make progress following debates such as this one.

Inspectors from the Care Quality Commission visited Southern Health as part of the planned inspection during January of this year. Following that inspection, the CQC announced on 6 April that it had issued a warning notice to Southern Health, telling the trust that it must make significant improvements to protect patients at risk of harm while in the care of its mental health and learning disability services. The announcement stated that the notice required the trust to improve its governance arrangements to ensure that there was robust investigation and learning from incidents and deaths, to reduce further risks to patients.

The team of inspectors also checked on improvements that had been required in some of the trust’s mental health and learning disability services following previous inspections. They found that the trust had failed to mitigate significant risks posed by some of the physical environments from which it delivered mental health and learning disability services.

On the wider issue of reporting deaths, the inspectors found that the trust did not operate effective governance arrangements to ensure robust investigation of incidents, including deaths; did not adequately ensure that it learned from incidents, so as to reduce future risk to patients; and did not effectively respond to concerns about safety that had been raised by patients, their carers and staff, or to concerns raised by trust staff about their ability to carry out their roles effectively.

All those findings, and the serious step of issuing a warning notice, reinforce the most serious of the Mazars findings. Dr Paul Lelliott, the CQC’s deputy chief inspector of hospitals and lead for mental health, was quoted as saying that the services provided by Southern Health required “significant improvement”. He said:

“We found longstanding risks to patients, arising from the physical environment, that had not been dealt with effectively. The Trust’s internal governance arrangements to learn from serious incidents or investigations were not good enough, meaning that opportunities to minimise further risks to patients were lost.

It is only now, following our latest inspection and in response to the warning notice, that the Trust has taken action and has identified further action that it will take to improve safety at Kingsley ward, Melbury Lodge in Hampshire and Evenlode in Oxfordshire. The Trust must also continue to make improvements to its governance arrangements for reporting, monitoring, investigating and learning from incidents and deaths. CQC will be monitoring this Trust very closely and will return to check on improvements and progress in the near future.”

The CQC published the full report of its January 2016 inspection at the end of April 2016. It confirmed the concerns that had been raised in the warning notice and gave further details of specific issues. The chairman of Southern Health’s board, Mike Petter, resigned the day before the report was published.

On the same day that the CQC published its warning notice, NHS Improvement issued a statement announcing that it was seeking further powers to intervene in the trust’s governance, to ensure that the trust complies with the improvements required of it. NHS Improvement said that it intended to insert an additional condition into the trust’s licence to supply NHS services, which would allow NHS Improvement to make management changes at the trust if progress was not made on addressing the concerns that had been raised.

The additional condition was imposed on 14 April, and the statutory notice contained severe criticism of the trust and its leadership. It stated that undertakings that the trust gave in April 2014 that it would comply with enforcement notices relating to breaches of its governance conditions were yet to be delivered in full. It notes that additional undertakings were made by the trust in January 2016 in response to the Mazars report and summarises the CQC’s findings from its inspection in January, saying that the warning notice had identified “longstanding risks to patients” that had not been addressed. It then said:

“In the light of these matters, and the other available evidence, Monitor”—

that is, NHS Improvement—

“is satisfied that the Board is failing to secure compliance with the Licensee’s licence conditions and failing properly to take steps to reduce the risk of non-compliance. In those circumstances, Monitor is satisfied that the governance of the Licensee is such that the Licensee is failing and will fail to comply with the conditions of its licence.”

On that basis, NHS Improvement, or Monitor, has imposed a new condition to Southern Health’s licence, requiring that it

“has in place sufficient and effective board, management and clinical leadership capacity and capability, as well as appropriate governance systems and processes, to enable it to”

address the failures in governance

“and comply with any enforcement undertakings, or discretionary requirements, imposed by Monitor in relation to these issues.”