Jeremy Hunt announces 'immediate' steps to be taken over leaked report into Southern Health

Health secretary Jeremy Hunt spoke in parliament this morning about the leaked report into avoidable deaths at Southern Health NHS Foundation Trust

‘Ofsted-style’ ratings of the care provided to people with learning disabilities in all clinical commissioning group areas will be published, health secretary Jeremy Hunt said this morning.

Mr Hunt was responding to an urgent question from shadow health secretary Heidi Alexander about a leaked report into avoidable deaths at Southern Health NHS Foundation Trust. 

A report, obtained by the BBC, said the trust had failed to investigate the unexpected deaths of more than 1,000 people since 2011. 

The review of deaths between April 2011 and March 2015 found 10,306 people had died and 1,454 of the deaths were unexpected. 

But the report, commissioned by NHS England and carried out by audit providers Mazars, found that of the unexpected deaths, only 195 (13%) were treated by the trust as a serious incident requiring investigation. 

The likelihood of a death being investigated depended on the type of patient.

Nearly a third (30%) of unexpected deaths of adults with mental health problems were investigated.

But the proportion of unexpected deaths which were investigated were far smaller for people with learning disabilities and over-65s with mental health problems – 1% and 0.3% respectively. 

Speaking in parliament this morning, Mr Hunt said the whole house would be ‘profoundly shocked’ by the findings. 

He said the draft report, which was submitted to NHS England in September, showed a lack of leadership and focus and insufficient time being spent investigating unexpected deaths of mental health and patients with learning disabilities.  

Mr Hunt said this should not be considered as an issue at just one NHS trust and added that ‘we have to move away from a blame culture so doctors and nurses are supported to speak out’. 

The health secretary said three immediate steps are being taken to create a ‘change in the culture’ to improve investigations and the learning from them.

The 209 clinical commissioning group areas will publish ratings on the quality of care offered to people with learning disabilities from next June. 

NHS England has commissioned the University of Bristol to investigate the mortality rates of people with learning disabilities in NHS care. 

NHS trusts will also publish figures on avoidable deaths at their organisations. 

Southern Health is one of the largest providers of community health, specialist mental health and learning disability services in the UK, covering Hampshire, Dorset, Wiltshire, Oxfordshire and Buckinghamshire.

It has said it has ‘serious concerns about the draft report’s interpretation of the evidence’.

While accepting that its reporting processes following a patient death have ‘not always been good enough’, it said it has taken considerable measures to strengthen its investigations and learning.

The trust said ‘in almost all the cases referred to in the report, the trust was not the main provider of care’. 

A statement added: ‘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.

‘When the final report is published by NHS England we will review the recommendations and make any further changes necessary to ensure the processes through which we report, investigate and learn from deaths are of the highest possible standard.’

Mr Hunt said the report will be published before Christmas and that publication had been delayed while the trust responded to it and because it had raised questions over the methodology.

It was commissioned in 2013 following the death of 18-year-old Connor Sparrowhawk who drowned in a bath in a Southern Health hospital in Oxford following an epileptic seizure. 

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.’


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