Southern Health NHS Foundation Trust — House of Lords, 2015-12-10
Topic: Health
David Prior (Conservative, Centre-right): My Lords, I shall now repeat as a Statement the Answer to an Urgent Question given in another place by my right honourable friend the Secretary of State for Health on the report into the investigation into deaths at Southern Health NHS Foundation Trust. "Mr Speaker, the whole House will be profoundly shocked by this morning’s allegations of a failure to investigate more than 1,000 unexpected deaths by Southern Health NHS Foundation Trust. Following the tragic death of 18 year-old Connor Sparrowhawk at Southern Heath NHS Foundation Trust’s short-term assessment and treatment unit in Oxfordshire in July 2013, NHS England commissioned a report from audit providers Mazars into unexpected deaths between April 2011 and March 2015 The draft report, submitted to NHS England in September, found a lack of leadership, focus and sufficient time spent in the trust on carefully reporting and investigating unexpected deaths of mental health and learning disability service users. Of 1,454 deaths reported, only 272 were investigated as critical incidents, and only 195 of those were reported as serious incidents requiring investigation. The report found there had been no effective systematic management and oversight of the reporting of deaths and the investigations that followed Prior to publication or, indeed, showing the report to me, NHS England rightly asked the trust for its comments. It accepted failures in its reporting and investigations into unexpected deaths but challenged the methodology, in particular pointing out that a number of the deaths were outpatients for whom it was not the primary care provider. However, NHS England has assured me that the report will be published before Christmas, and it is our intention to accept the vast majority, if not all, of the recommendations it makes Our hearts go out to the families of those affected. More than anything, they want to know that the NHS learns from tragedies such as what happened to Connor Sparrowhawk, and that is something we patently fail to do on too many occasions at the moment. Nor should we pretend that this is as a result of the wrong culture at just one NHS trust. There is an urgent need to improve the investigation and learning from the estimated 200 avoidable deaths that we have every week across the system I will give the House more details about the report and its recommendations when I have had a chance to read the final version and understand its recommendations, but I can tell the House about three important steps that will help to create the change in culture we need. First, it is totally and utterly unacceptable that only 1% of the unexpected deaths of patients with learning disabilities were investigated, so from next June we will publish independently assured Ofsted-style ratings of the quality of care offered to people with learning disabilities for all 209 CCG areas. This will ensure that we shine a spotlight on the variations in care, allowing rapid action to be taken when standards fall short Secondly, NHS England has commissioned the University of Bristol to undertake an independent study of mortality rates of people with learning disabilities Thirdly, I have committed to the House previously that next year we will publish the number of avoidable deaths by NHS trust. Professor Sir Bruce Keogh has worked hard to develop a methodology to do this and will write to medical directors at all trusts in the next week explaining how it works and asking them to supply estimated figures that can be published in the spring. Central to this will be instilling a no-blame reporting culture across the NHS where people are rewarded, not penalised, for speaking openly and transparently about mistakes Finally, I pay tribute to Connor’s mother, Sara Ryan, who has campaigned tirelessly to get to the bottom of these issues. Her determination to make sure the right lessons are learnt from Connor’s unexpected and wholly preventable tragic death is an inspiration to us all. Today, I would like to offer her and all other families affected by similar tragedies a heartfelt apology on behalf of the Government and the NHS".