NHS death investigations to be reviewed

The statement coincides with the report on mental health trust, Southern Health NHS Foundation Trust, which identified a ‘lack of leadership, focus and sufficient time spent’ when investigating deaths.

The Southern Health NHS Foundation Trust covers Hampshire, Dorset, Wiltshire, Oxfordshire and Buckinghamshire, and provides services to about 45,000 people. Hunt maintained he was determined that the NHS learned lessons from the report.

The report was ordered in 2013, after 18-year-old Connor Sparrowhawk drowned in a bath following an epileptic seizure while a patient at the hospital. The investigation found his death to have been preventable, with neglect by the Trust contributing to his death.

The report also showed there had been over 10,000 deaths at the Trust between 2011-15, with 722 unexpected deaths and only 272 prompting investigation.

The investigations that did take place were said to be too long and of ‘poor’ quality, while coroners raised concerns that ’no effective action was taken’.

Data also exhibited that 30 per cent of all deaths were investigated in adult mental health services, with fewer than one per cent of deaths of people with learning difficulties investigated. Furthermore, only 0.3 per cent of deaths in older people suffering from mental health problems were investigated.

In a statement to Parliament, Hunt wrote: "I am determined that we learn the lessons of this report, and use it to help build a culture in which failings in care form the basis for learning for organisations and for the system as a whole."

The Care Quality Commission (CQC) has said it will launch a ‘focused inspection’ on Southern Health.

Hunt added the CQC would ‘also be undertaking a wider review into the investigation of deaths in a sample of all types of NHS trust in different parts of the country’.

He said: “As part of this review, we will assess whether opportunities for prevention of death have been missed, for example by late diagnosis of physical health problems."

Katrina Percy, the chief executive at Southern Health, said the report looked into patients who had had any contact with Southern Health and that ‘in most cases referred to in the report, the trust was not the main care provider’.

Percy added: "We fully accept that our processes for reporting and investigating deaths of people with learning disabilities and mental health needs were not always as good as they should have been.

"We also fully acknowledge that this will have caused additional pain and distress to families and carers already coping with the loss of a loved one.

"We apologise unreservedly for this and recognise that we need to make further improvements."

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