MP Jeremy Hunt has told the commons that there is “urgent need” to improve the investigations into the 200 avoidable deaths each week in the NHS, and better understanding from Hospital Trusts to learn from these mistakes.
This statement comes after a report by NHS England found the unexpected deaths of more than 1000 mental health patients at Southern Health NHS Foundation Trust were not investigated.
Southern Health provides mental health services to around 45,000 people in Hampshire, Dorset, Wiltshire, Oxfordshire, and Buckinghamshire. It is one of the country’s largest Trusts.
The leaked report looked into all deaths between April 2011 and March 2015. It found that whilst most of the deaths were expected, 1,454 were not.
Out of the unexpected deaths 272 were classed as critical incidents by the Trust – yet only 195 of those were treated as a serious incident requiring investigation.
The report into the Trust was ordered in 2013 after the death of 18-year-old Connor Sparrowhawk. Mr Sparrowhawk was a patient at a Southern Health Hospital in Oxford when he drowned in a bath following an epileptic fit.
An independent investigation found that his death had been preventable and an inquest found that failings by the Trust had led to his death.
This report highlights the systemic lack of consistent processes in the NHS which leads to unnecessary deaths of patients.
The report highlights the Trust failing to use the data it holds on deaths in an effective way to learn.
The likelihood of an unexpected death being investigated hugely depended on the type of patient, the report stated. For those with learning difficulties, the figure was just 1% and the over-65s with mental health problems was just 0.3%.
The report places full responsibility for the failings with the senior executives and the Trust board, which has been led by Katrina Percy since it was created in 2011.
The report says the culture at Southern Health “results in lost learning, a lack of transparency when care problems occur, as well as a lack of assurance to families that a death was not avoidable and has been properly.
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