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Southern Health chairman quits after damning report by inspectors Southern Health chairman quits after damning report by inspectors
(about 1 hour later)
The chairman of a NHS mental health trust that was told it was not doing enough to investigate unexpected deaths has resigned after an inspection found there were still serious concerns about the safety of patients. The chairman of an NHS mental health trust that was told it was not doing enough to investigate unexpected deaths has resigned after an inspection found there were still serious concerns about the safety of patients.
A team from the Care Quality Commission (CQC), which regulates health and social care services, said Southern Health had not made effective arrangements for responding to concerns raised by patients, their carers or staff.A team from the Care Quality Commission (CQC), which regulates health and social care services, said Southern Health had not made effective arrangements for responding to concerns raised by patients, their carers or staff.
Inspectors said they found “ligature risks” in acute mental health wards, despite three earlier warnings about the dangers they posed. A protocol for safe bathing for people with epilepsy had not been signed off, three years after an 18-year-old drowned in a bath after suffering an epileptic fit.Inspectors said they found “ligature risks” in acute mental health wards, despite three earlier warnings about the dangers they posed. A protocol for safe bathing for people with epilepsy had not been signed off, three years after an 18-year-old drowned in a bath after suffering an epileptic fit.
The snap inspection was carried out a month after an independent review said Southern Health had failed to properly investigate more than 1,000 deaths. Before the report’s publication on Friday, Southern Health’s chairman, Mike Petter, announced he would be stepping down.The snap inspection was carried out a month after an independent review said Southern Health had failed to properly investigate more than 1,000 deaths. Before the report’s publication on Friday, Southern Health’s chairman, Mike Petter, announced he would be stepping down.
“The trust has recently undergone a significant amount of scrutiny in some service areas and, given the challenges it faces, I feel it is appropriate for me to allow new board leadership to take forward the improvements,” he said in a statement.“The trust has recently undergone a significant amount of scrutiny in some service areas and, given the challenges it faces, I feel it is appropriate for me to allow new board leadership to take forward the improvements,” he said in a statement.
Twenty-two inspectors carried out the short-notice inspection of Southern Health’s sites over four days in January, speaking with patients, carers, staff, whistleblowers and the trust’s board. They found that the trust still lacked “robust governance arrangements” for investigating incidents, learning from them and making sure they did not happen again.Twenty-two inspectors carried out the short-notice inspection of Southern Health’s sites over four days in January, speaking with patients, carers, staff, whistleblowers and the trust’s board. They found that the trust still lacked “robust governance arrangements” for investigating incidents, learning from them and making sure they did not happen again.
Although some improvements had been made, there were still inconsistencies in the recording of incidents, problems with the management of complaints and a poor understanding of risks in wards.Although some improvements had been made, there were still inconsistencies in the recording of incidents, problems with the management of complaints and a poor understanding of risks in wards.
Last year NHS England hired Mazars, an audit firm, to examine 10,306 patient deaths at Southern Health between April 2011 and March 2015, 1,454 of which had been unexpected. It concluded that failures by the trust’s board and senior executives meant there was no “effective” management of deaths or investigations and a lack of “effective focus or leadership from the board”.Last year NHS England hired Mazars, an audit firm, to examine 10,306 patient deaths at Southern Health between April 2011 and March 2015, 1,454 of which had been unexpected. It concluded that failures by the trust’s board and senior executives meant there was no “effective” management of deaths or investigations and a lack of “effective focus or leadership from the board”.
In 2013 Connor Sparrowhawk, an 18-year-old with learning disabilities, drowned in a bath at the trust’s Slade House unit in Oxfordshire after suffering an epileptic seizure. The Mazars report said coroners had criticised the trust during inquests for producing reports that were inadequate or very late, but it said that had failed to prompt the improvements that were needed, and staff often made little effort to engage with the relatives of those who had died.In 2013 Connor Sparrowhawk, an 18-year-old with learning disabilities, drowned in a bath at the trust’s Slade House unit in Oxfordshire after suffering an epileptic seizure. The Mazars report said coroners had criticised the trust during inquests for producing reports that were inadequate or very late, but it said that had failed to prompt the improvements that were needed, and staff often made little effort to engage with the relatives of those who had died.
Dr Paul Lelliott, the CQC’s deputy chief inspector of hospitals, said: “We found that in spite of the best efforts of the staff, the key risks and actions to address them were not driving the senior leadership or board agenda. It is clear that the trust had still missed opportunities to learn from adverse incidents and to take action to reduce the chance of similar events happening in the future.Dr Paul Lelliott, the CQC’s deputy chief inspector of hospitals, said: “We found that in spite of the best efforts of the staff, the key risks and actions to address them were not driving the senior leadership or board agenda. It is clear that the trust had still missed opportunities to learn from adverse incidents and to take action to reduce the chance of similar events happening in the future.
“For example, although the trust had identified that when people did not attend appointments they could be at high risk of harm, there was no clear guidance for staff working in community mental health teams about what they should do when a patient does not attend an appointment.”“For example, although the trust had identified that when people did not attend appointments they could be at high risk of harm, there was no clear guidance for staff working in community mental health teams about what they should do when a patient does not attend an appointment.”
Concerns raised previously about the physical environment were not being acted on, Lelliott said. A low roof in a garden attached to an acute mental health ward had not been made inaccessible, despite patients climbing up it and falling off, and in one case using it as a route to escape.Concerns raised previously about the physical environment were not being acted on, Lelliott said. A low roof in a garden attached to an acute mental health ward had not been made inaccessible, despite patients climbing up it and falling off, and in one case using it as a route to escape.
“I am concerned that the leadership of this trust shows little evidence of being proactive in identifying risk to the people it cares for or of taking action to address that risk before concerns are raised by external bodies,” the inspector said.“I am concerned that the leadership of this trust shows little evidence of being proactive in identifying risk to the people it cares for or of taking action to address that risk before concerns are raised by external bodies,” the inspector said.
Katrina Percy, chief executive of Southern Health, said: “Today’s CQC report sends a clear message to the leadership of the trust that more improvements must be delivered and as rapidly as possible … We fully accept that until we address all these concerns and our new reporting and investigating procedures introduced in December 2015 are completely effective, we will remain, rightly, under intense scrutiny.”Katrina Percy, chief executive of Southern Health, said: “Today’s CQC report sends a clear message to the leadership of the trust that more improvements must be delivered and as rapidly as possible … We fully accept that until we address all these concerns and our new reporting and investigating procedures introduced in December 2015 are completely effective, we will remain, rightly, under intense scrutiny.”