NHS 'failed to investigate 1000 deaths'

Laura Donnelly By Laura Donnelly

The NHS has failed to investigate the unexpected deaths of more than 1,000 people since 2011, a report has found.

Charities called for action to tackle “a national scandal” and said hundreds of people with learning disabilities were dying needlessly amid failings in care, without lessons being learned.

A report obtained by the BBC says a "failure of leadership" at Southern Health NHS Foundation Trust meant deaths of mental health and learning-disability patients were not properly examined.

The investigation was ordered after the death of one the trust’s patients, Connor Sparrowhawk, 18, who drowned in a bath in July 2013 following an epileptic seizure.

An independent probe said his death in Oxford had been preventable, and an inquest jury found neglect by the trust had contributed to his death.

The trust, one of the largest community health, specialist mental health and learning disability services in the country, covers Hampshire, Dorset, Wiltshire, Oxfordshire and Buckinghamshire.

The investigation, commissioned by NHS England and carried out by Mazars, a large audit firm, looked at all deaths at the trust between April 2011 and March 2015.

It found 10,306 people had died - including 1,454 deaths which were not expected.

Of those, just 195 were treated by the trust as a serious incident requiring investigation.

Deaths of patients with learning disabilities and elderly people with mental health problems were the least likely to be probed.

"There are serious concerns about the draft report's interpretation of the evidence."

Just one per cent of deaths of those with learning disabilities were investigated, along with 0.3 per cent of over-65s with mental health problems, the report said.

The average age at death of those with a learning disability was 56 - over seven years younger than the national average.

The trust disputed some of the findings. In a statement last night it said: “We recognise the numbers in this draft report but they have been completely misinterpreted.

“More than half of the 1,454 deaths quoted in the draft report were expected and of those that were initially reported as unexpected, the majority were not clinically avoidable.

“Of the 1,454, more than 90 per cent were deaths of people not in our hospitals. It was not usually Southern Health’s responsibility to investigate the circumstances surrounding these deaths."

“Where there is any concern about the circumstances surrounding a person’s death, the Trust would either investigate or support an investigation by another health or social care body.”

The report lays the blame with the trust board, led by Katrina Percy since 2011, accusing it of failing to show effective leadership.

It concludes: “"We have little confidence that the trust has fully recognised the need for it to improve its reporting and investigation of deaths."

Connor's mother, Sara Ryan, called for the entire leadership of Southern Health to resign.

"1,200 people with a learning disability are dying avoidably in the NHS every year. This is a national scandal"

She said: "There is no reason why in 2015 a report like this should come out. It's a total scandal. It just sickens me."

Southern Health NHS Foundation Trust said: "There are serious concerns about the draft report's interpretation of the evidence."

It said the trust "fully accept" its reporting of patient deaths had not been good enough and "considerable measures" had been take to improve investigations of deaths.

It said: "We would stress the draft report contains no evidence of more deaths than expected in the last four years of people with mental health needs or learning disabilities for the size and age of the population we serve."

An NHS England spokesperson said: "We commissioned an independent report because it was clear that there are significant concerns. We are determined that, for the sake of past, present and future patients and their families, all the issues should be examined and any lessons clearly identified and acted upon.

“The final full independent report will be published as soon as possible, and all the agencies involved stand ready to take appropriate action.

Jan Tregelles, chief executive of Mencap, said: “1,200 people with a learning disability are dying avoidably in the NHS every year. This is a national scandal.

“One of the key recommendations of the government commissioned ‘Confidential Inquiry into premature deaths of people with learning disability’ was the importance of proper analysis into the deaths of people with a learning disability. Only then we will be able to identify the causes of avoidable deaths and ensure that they are properly addressed.

"Mencap’s Death By Indifference campaign has highlighted the lack of value and lack of priority placed on the lives of people with a learning disability. This is a very real crisis that is happening to people with a learning disability and their families across the UK right now. When the final report is published we will be looking very carefully at the recommendations, as we remain extremely concerned about the lack of progress on this issue by government and the NHS.”/Telegraph