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Mental health trust fails to investigate patient deaths, CQC says


29 April 2016

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One of England’s largest mental health trusts which ran a care unit where a teenager drowned has failed to investigate patient deaths, the Care Quality Commission (CQC) said.

A team of 22 inspectors visited Southern Health NHS Foundation Trust in January on a short-notice inspection to check whether it had made improvements following a comprehensive inspection in 2014. Teenager Connor Sparrowhawk died in a bath after an epileptic seizure the previous year, sparking an investigation into other deaths.

One of England’s largest mental health trusts which ran a care unit where a teenager drowned has failed to investigate patient deaths, the Care Quality Commission (CQC) said.

A team of 22 inspectors visited Southern Health NHS Foundation Trust in January on a short-notice inspection to check whether it had made improvements following a comprehensive inspection in 2014. Teenager Connor Sparrowhawk died in a bath after an epileptic seizure the previous year, sparking an investigation into other deaths.

Trust chairman Mike Petter resigned yesterday in advance of the report to allow new leadership to continue improvements.

The CQC said today that the trust which provided services in Hampshire, Dorset, Wiltshire and Buckinghamshire had not put robust arrangements in place to investigate patient deaths and had missed opportunities to learn from incidents.

The CQC’s lead for mental health and deputy chief inspector of hospitals Dr Paul Lelliott said: “We found that in spite of the best efforts of staff, the key risks and actions to address them were not driving the senior leadership or board agenda.”

Lellicott added: “I am concerned that the leadership of this trust shows little evidence of being proactive in identifying risk to the people it cares for or of taking action to address that risk before concerns are raised by external bodies.”

Commissioners told inspectors they were concerned about the timely reporting of serious incidents.

NHS England and commissioners now hold monthly oversight meetings with the trust to monitor health and safety issues.

The trust held a conference on serious incidents last October and a follow up conference was due in February after its inspection, the CQC noted.

Inspectors were concerned that insufficient action had been taken over concerns about ligature risks in acute mental health and learning disability services despite highlighting them several times.

They asked the trust to take immediate action to stop patients accessing a low roof at one site, where there had “been a number of incidents of patients injuring themselves, some seriously, by falling from the roof.”

Lellicott said the trust had opportunities to learn from adverse incidents and prevent their reoccurrence.

“Although the trust had identified that when people did not attend appointments, they could be at high risk of harm, there was no clear guidance for staff working in community mental teams about what they should do when a patient does not attend an appointment.”

The CQC noted some improvements, including better support for acutely unwell patients in community services in Southampton and avoiding multiple transfers between teams for patients admitted or discharged from hospital.

The trust’s chief executive Katrina Percy said the report sent a clear message that improvements must be made.

“I am absolutely focused on addressing the CQC’s concerns and supporting our staff to provide the best care possible.”

She said new reporting investigating procedures were introduced in December 2015.

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