Staff not to blame for failings at mental health trust
CQC inspectors find 'despite best efforts', risks identified were not prioritised by senior leadership or board
The entire board of Southern Health NHS Foundation Trust is facing calls to resign, following a damning report by the Care Quality Commission (CQC).
In January, CQC inspectors reviewed patient notes, serious incident reports and complaint procedures at the trust, which provides mental health and learning disabilities services and runs care homes in Hampshire, Dorset, Wiltshire, Oxfordshire and Buckinghamshire.
They found only 272 of 722 unexpected deaths at the trust between April 2011 and March 2015 had been investigated.
One of the most high-profile cases involved the death of Connor Sparrowhawk, who drowned after an epileptic seizure while left alone in a bath at Slade House in Headinton in 2013.
Politicians and campaigners have called on the trust board to accept collective responsibility for the failings identified, including a lack of robust governance arrangements, missed opportunities to learn from errors, staff concerns being ignored and serious safety risks to vulnerable patients.
CQC deputy chief inspector of hospitals and lead for mental health Paul Lelliott said: ‘We found in spite of the best efforts of the staff, the key risks and actions to address them were not driving the senior leadership or board agenda.’
He said staff in community mental health teams lacked guidance about the required actions when patients failed to attend appointments and were unsure when and how to involve patients’ families following serious incidents.
He vowed the CQC would be ‘monitoring progress extremely closely’ and said a future inspection would take place to ensure required improvements had been made and were being sustained.
The inspection was requested by the health secretary following publication of the independent Mazars review into the trust in December last year.
Trust chair Mike Petter stepped down yesterday (April 28) ahead of the publication of the CQC report.
His departure was followed by the resignation of governor Mark Aspinall, amid calls for chief executive Katrina Percy to follow suit – something she insists she will not do.
Ms Percy said the findings sent a clear message that more improvements must be delivered ‘as rapidly as possible’ and pledged to share updates on progress to ‘help re-build trust in our services’.
Connor Sparrowhawk's mother Sarah Ryan issued a statement calling on the entire board to resign and expressing her dismay at the lack of action by NHS Improvement.
In response, the new health regulator said it recognised the seriousness of the situation and was considering whether to take any further regulatory action.
Read the full CQC report here