Boss of mental health trust apologises for failing to investigate deaths properly

Patient: Mark O'Shaughnessy was known to Southern Health
Patient: Mark O'Shaughnessy was known to Southern Health
  • Chief executive apologises unreservedly
  • Changes have been made to improve reporting
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THE boss of a Hampshire health trust has ‘apologised unreservedly’ for failing to investigate the deaths of hundreds of people with learning difficulties or mental health care needs it dealt with.

An independent review last week found that 1,100 deaths of people with mental health problems and learning disabilities, who were helped by Southern Health NHS Foundation Trust, were not looked into properly and meant chances to learn from them had been missed.

We fully accept a need to continue to make changes, and will work with our commissioners and regulatory bodies to make the improvements required.

Katrina Percy, chief executive of Southern Health NHS Foundation Trust

Today, Katrina Percy, chief executive of Southern Health, has apologised for this and said changes have been made.

She said: ‘We fully accept 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.

‘In the past, our engagement with families and carers of people who have died in our care has not always been good enough.

‘While we have already made substantial changes in how we approach this, we have more improvements to make.’

Commissioner NHS England South paid for auditors Mazars to look at more than 10,000 deaths at the trust between April 2011 and March 2015, of which 1,454 were unexpected.

It found just 195 – 13 per cent – were treated as a ‘serious incident requiring investigation’ and the likelihood of an unexpected death being investigated depended hugely on the type of patient.

The trust said it has since made changes which include:

– Significantly strengthening executive oversight of the quality of investigations and ensuring appropriate measures are in place to address any issues identified, and that all learning is shared and implemented across the trust.

– New executive level doctors and nurses joined the trust board from July 2014.

– Setting up a new central investigation team which is improving the quality and consistency of investigations and learning.

– Capturing conclusions of inquests more effectively to identify and act swiftly on areas for improvement.

–Launching a new system for reporting and investigating deaths in consultation with our commissioners to increase monitoring, scrutiny and learning.

– Providing every family with the opportunity to be involved in investigations relating to a death of a loved one.

Ms Percy added: ‘We fully accept a need to continue to make changes, and will work with our commissioners and regulatory bodies to make the improvements required.

‘Our main focus continues to be ensuring that everyone who relies on the services we provide receives the best possible care.

‘Reports such as this challenge not only Southern Health, but the wider health and social care system, and society as a whole, to reflect on the way we support, include, and value people with learning disabilities and mental health needs.

‘All providers and commissioners of care can learn from this report. It states that current NHS guidance should be revised to clarify which organisation should lead the investigation into a person’s death when more than one provider is involved in their care.

‘We are keen to contribute to this.

‘It’s important to make clear that the report looked at the way the trust recorded and investigated deaths of people with mental health needs and learning disabilities who had been in contact with Southern Health staff at least once in the previous year. In most cases referred to in the report, the trust was not the main care provider.

‘The review did not consider the quality of care provided by the trust to the people we serve.

‘National data on mortality rates confirms that the trust is not an outlier. We believe that Southern Health’s rate of investigations into deaths is in line with that of similar NHS organisations.’

Relatives concerns

RELATIVES of people who had died have previously raised care concerns about Southern Health NHS Foundation Trust to The News.

In February 2013, Mark O’Shaughnessy, 28, from Williams Close, Gosport, hanged himself the day after telling health professionals

that he wanted to kill himself and hurt his mum, Julie.

The mental health services decided to keep him at his house rather than section him in a psychiatric ward.

Craig Sheer, a 33-year-old dad of-one, of Woodcot Crescent, Havant, was found dead in August 2013, after gassing


Three weeks earlier he had been discharged from Elmleigh hospital in Havant after a two-day stay.

Mr Sheer had admitted himself to the hospital after having suicidal thoughts and his family said he should have been kept in for assessment.

On July 4, 2014, Joanna Lynch, Horndean, was found dead at home after an overdose of prescription medication.

Miss Lynch had been in touch with the trust’s mental health helpline Hospital at Home and had begged for help in the weeks leading up to her death.

In each case Southern Health said it had learnt lessons and made changes and improvements.