Edward Hartley, 18, from Wickham died following an epileptic seizure at home on May 28, 2014 and was found in his bed by a Southern Health NHS Foundation Trust carer.
His parents Ian and Jane have spent the last six years fighting for answers and now a report commissioned by NHS England to look into the trust as a whole has concluded that a public investigation should take place – with potential payments to the families involved.
Mum Jane said: ‘This investigation has been a long time coming and if you speak to any of the families involved you will see that we are bruised and battered from what we have been through.
‘We have been fighting hard for this investigation and it has been tough. There needs to be a change in attitude and culture towards these investigations.
‘Dr Broughton had a real opportunity to resolve over cases but for whatever reason chose another route. His distancing himself from the Trust’s failures to investigate is offensive.’
The report by Nigel Pascoe QC, which was commissioned in June last year, also considered the deaths of Robert Small, 28, from Fareham, who had a history of depression and died in 2012, David West, 28, from Southampton, who had a history of mental health problems and died in 2013 and 74-year-old Marion Munns from Southampton, who had a mental breakdown and died in 2015.
Mr Pascoe stated: ‘In the various deaths between 2011 and 2015 that I have been considering, there have been significant, serious and deeply regrettable failures by the trust into their proper investigation and reasonable communication with immediate family members.
‘Those combined failures, taken with failures of care before death, together have caused real and long-lasting harm.
‘I conclude that it is essential that in any public investigation, all relatives should have the opportunity to give evidence or provide written statements if they wish to do so.
‘The reason is not for them to have to relive their individual traumas, but to give effect to the express wishes of every family member to promote constructive and effective reform of the present processes of this trust.’
In response to the report Dr Nick Broughton, current chief executive of the trust said: ‘The deaths of the four people included in this report have had an immeasurably devastating impact on their families. This report reinforces our own view: that at times the trust’s response to families’ understandable concerns added to their distress at an already difficult time. This is completely unacceptable: I am profoundly sorry, and on behalf of the trust I apologise.
‘The trust has made significant changes since the period covered by this report. In many cases these changes have been as a direct result of contribution from families and learning from past failings. Southern Health is now rated Good by the Care Quality Commission, having previously been rated as Requires Improvement. Whilst this is encouraging we remain committed to making further improvements.’
Campaigner Geoff Hill has been fighting for reform in Southern Health for many years and has supported the families.
He said: ‘This report means that the families have got justice but not yet accountability.’
It comes as Southern Health chief executive Dr Broughton announces that he will be leaving the trust in May to take up a role as chief executive of Oxford Health NHS Foundation Trust due to his family living in Oxfordshire.
Dr Broughton said: ‘I am pleased that together with colleagues we have made significant improvements at Southern Health over the last two years. I have every confidence in the trust board and staff to continue to make improvements in care for local people.’