Summary
NHS England has released the independent report by Mazars (an early copy of which was leaked a week before) concerning the deaths of people with learning disabilities or mental health problems at Southern Health NHS Foundation Trust.
“The report does not specify how many investigations there should have been, but draws attention to the limited number of deaths that were investigated in different categories”.
The numbers are not on the scale indicated earlier, but still reflect a significant underlying problem, for which there is now likely to be a thorough investigation. There were over 10,000 deaths at the trust between 2011 and 2015, of which 722 were unexpected deaths; only 272 of the latter group were investigated properly.
Reference
NHS England publishes report into Southern Health. London: NHS England, December 17th 2015.
“ …while 30% of all deaths were investigated in adult mental health services, fewer than 1% of deaths of people with learning disabilities were investigated and 0.3% of deaths in older people with mental health problems”.
Reference
NHS death investigations to be reviewed. London: BBC Health News, December 17th 2015.
This relates to:
Reference
Independent review of deaths of people with a Learning Disability or Mental Health problem in contact with Southern Health NHS Foundation Trust. April 2011 to March 2015. Final version for publication. London: NHS England / Mazars, December 17th 2015.
There is a joint response from NHS Improvement (which includes Monitor, the regulator of Foundation Trusts), NHS England and the Care Quality Commission:
Reference
NHS Improvement response to the report into Southern Health. London: Monitor, NHS Trust Development Authority, NHS England and Care Quality Commission, December 18th 2015.
Freedom of Information (FOI) requests made by the Guardian newspaper suggest that inadequate NHS investigations into unexpected deaths in mental health trusts could be more widespread:
Reference
Pym, H. (2015). Investigating unexpected deaths – unanswered questions for the NHS. London: BBC Health News, December 21st 2015.
More Serious Incidents in English Mental Health Trusts
There were 8,139 serious incidents reported by the 58 mental health trusts in England during 2014-15 (an increase of over a third during the previous two-year period), according to figures obtained under Freedom of Information (FOI) by the Liberal Democrats:
Reference
Pym, H. (2016). Rise in serious incidents at English mental health trusts. London: BBC Health News, January 26th 2016.
The charity Inquest believes that at least nine young people have died in England as in-patients since 2010.
Reference
Marshall, P. (2016). Mental health deaths under-reported, says charity. London: BBC Health News / BBC One Panorama, April 11th 2016.
April 2016 Update
The Care Quality Commission (CQC) has remaining concerns about improvements at Southern Health NHS Foundation Trust:
Reference
Criticised Southern Health NHS Foundation Trust ‘must improve’. London: BBC Health News, April 6th 2016.
Background
Some other independent quality improvement-related reports commissioned by NHS England (South):
Reference
Independent investigation reports for the South. [Online]: NHS England (South), December 2015.
