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Summary

Following the death of Connor Sparrowhawk in July 2013, NHS England commissioned an independent report into the deaths of people with a learning disability or mental health problem in contact with Southern Health NHS Foundation Trust. The independent report (the Mazars report) highlighted the failure of the trust to investigate and learn from the deaths of patients; particularly those receiving care.  This led to a CQC investigation in January 2016 and on 6 April 2016 the CQC issued a warning notice. The notice requires the trust to improve its governance arrangements to ensure robust investigation and learning from incidents and deaths, to reduce future risks to patients. The CQC inspectors were also checking on improvements, which had been required in some of the Trust’s mental health and learning disability services following previous inspections.

CQC inspectors found that the trust had failed to mitigate against significant risks posed by some of the physical environments from which it delivered mental health and learning disability services and did not operate effective governance arrangements to ensure robust investigation of incidents, including deaths. It did not adequately ensure it learned from incidents to reduce future risks to patients. In addition, inspectors found that the trust did not effectively respond to concerns about safety raised by patients, their carers and staff, or respond to concerns raised by Trust staff about their ability to carry out their roles effectively.

On 12 April 2016 CQC announced it would be carrying out a review of how NHS trusts identify, report, investigate and learn from deaths of people using their services. This followed a request from the Secretary of State for Health, which was part of the Government’s response to events at Southern Health NHS Foundation Trust. CQC’s wider review will consider the quality of practice in relation to identifying, reporting and investigating the death of any person in contact with a health service managed by an NHS trust; whether the person is in hospital, receiving care in a community setting or living in their own home. The review will pay particular attention to how NHS trusts investigate and learn from deaths of people with a learning disability or mental health problem.

Following the CQC warning notice, in April NHS Improvement also announced its intention to take regulatory action at the trust. NHS Improvement intends to put an additional condition in the trust’s licence to provide NHS services, which would allow it to make management changes at the trust if progress isn’t made on fixing the concerns raised. The trust has the opportunity to comment on NHS Improvement’s proposals before a final decision is made on whether to put the additional condition in its licence.

Further information on policies to improve services for people with learning disabilities, and reviews into premature deaths (including the National Learning Disability Mortality Review Programme which was announced in June 2015) can be found in a separate Library briefing:

http://researchbriefings.parliament.uk/ResearchBriefing/Summary/SN07058


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