Health regulator to support investigation of deaths at trust

Monitor will appoint director at Southern Health NHS Foundation Trust to improve reporting of unexpected incidents 

An NHS trust that failed to investigate the unexpected deaths of 89 people with learning disabilities is to be given extra support from Monitor, the health sector regulator in England. 

Southern Health NHS Foundation Trust investigated only four out of the 93 incidents between April 2011 and March 2015, according to an independent review by auditors Mazars. 

Monitor will appoint an improvement director for the trust to look at the reporting and investigation of deaths, particularly those of people with learning disabilities and mental health needs.  

The Mazars audit of 1,454 unexpected deaths at the trust found only 13% were treated by the trust as a serious incident requiring investigation.

Southern Health chief executive Katrina Percy said the report highlighted that the trust's ‘processes for reporting and investigating deaths of people with learning disabilities and mental health needs could have been better’.

She added: ‘The trust did not always involve families as much as we could have. We apologise unreservedly for this.’

Monitor said the trust has accepted the recommendations of the Mazars report, including that its board receives regular reports of all deaths and that it establishes a mental health and learning disability mortality review group.  

Southern Health will receive expert assurance on how well it plans and carries out the necessary improvements, Monitor said. 

The regulator's regional director Claudia Griffith said: ‘The NHS should take every opportunity to learn from any mistakes that happen when caring for people, to ensure that they are never repeated again.

‘However, it is also clear that more work is needed across the NHS to identify and spread best practice for reporting and investigating deaths among people with a learning disability and/or mental health needs.’

Learning disability charity Mencap's chief executive Jan Tregelles said Monitor’s announcement ‘offers little in the way of accountability of Southern Health leadership, and it is not clear how families will get answers about what happened to their loved ones’. 

She added: ‘Monitor and the Care Quality Commission have announced an investigation into how deaths of people with a learning disability are investigated across the NHS. 

‘They must set out a timetable for completing this and what it will cover, given concerns that the issues exposed at Southern Health may also be present in other parts of the health service.’


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