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Posted 14 April 2016
by Endurance Arthur

Southern Health Foundation Trust found to be non-compliant with standards and failing patients following investigation

Southern Health Foundation Trust has been warned by The Care Quality Commission (CQC) that it is failing to sufficiently protect tens of thousands of patients in its care. Southern Health Foundation Trust, which covers five counties and provides mental health and disability services for 45,000 patients, has been accused of exposing patients to long-standing risks and for failing to learn from its mistakes.

The Care Quality Commission is the independent regulator of health and social care in England and inspected the Trust in January 2016. This followed an independent report by Mazars, an international audit, tax and advisory firm, into the deaths of patients with Mental Health problems in their care from April 2011 to March 2015. The report identified 128 inpatient deaths up to 3rd March 2015, 24 of which were subsequently investigated as “Serious Incidents Requiring Investigation” (SIRIs).

One such death was that of Connor Sparrowhawk in 2013 at Slade House – a Learning Disability unit in Oxford – which is part of the Southern Health Foundation Trust. Connor had autism, epilepsy and learning difficulties and died in the bath after an epileptic fit.

An inquest in October 2015 found that Connor’s death was preventable and several failings, including neglect, contributed to his death. Connor was left alone in the bath and 15 to 20 minutes after last being checked was found under the water not breathing. Staff tried to resuscitate him to no avail – he was then taken to hospital and sadly died the same day.

A 2014 Verita report found that staff had failed to implement relevant tests and precautions relevant to his epilepsy, including failing to appropriately use the knowledge of his parents. Staff also failed to respond to and appropriately profile and risk assess Connor’s epilepsy, meaning that decisions such as that to observe him every 15 minutes in the bath, were poorly informed and failed to safeguard him.

D M Salter, Her Majesty’s Senior Coroner, wrote to Katrina Percy, the Chief Executive of the Southern Health Foundation Trust in a report to help prevent future deaths, stating that “future deaths will occur unless action is taken.” In an official statement, Katrina Percy admitted that the Trust had “failed to undertake the necessary actions required to keep him [Connor] safe.” D M Salter however criticised the steps the Trust took to address concerns following Connor’s death, including a ban on patients having baths altogether, and raised concerns about staff’s access to required information about epilepsy and patient history.

An independent review by Verita – an independent consultancy for regulated organisations in the UK – recommended to the Trust that it “may be advisable to improve on the relevant policies.” But concluded that though: “these shortcomings do not appear to have been significant factors in Mr Sparrowhawk’s death; they do appear to be matters where care could have been improved.” A 2014 Veritas report concludes that the death was preventable, had appropriate care planning been done regarding Mr Sparrowhawk’s epilepsy.

Interestingly, the 2015 Veritas report goes on to criticise the current Mental Health regime, saying that, “Neither the Mental Health Act nor the Deprivation of Liberty Safeguards,” are designed to address such questions. The report also criticises the current legislation, including its scope and how it fits in with other regulatory structures that are designed to ensure the provision of adequate care. These criticisms are especially pertinent at present as the Deprivation of Liberty Safeguards are currently under reconsideration by the Law Commission. Select Committees of both Houses of Parliament have criticised the Safeguards and called for the system to be reviewed.

These criticisms follow the case of Cheshire West and Chester Council v P which gave disabled persons greater protection as it held that mentally incapacitated persons have the same rights to liberty as everyone else: if their living arrangements amount to a deprivation of liberty of a non-disabled person then they were a deprivation of liberty of the disabled person.

Whilst the Trust have now taken action to improve patient safety, the Verita report and the CQC both indicate that further action and improvement is still required. The CQC have said they will continue to check the Trust and “will return to check on improvements and progress in the near future.”

A full CQC report into its January 2016 inspection of Southern Health NHS Foundation Trust is expected to be published in late April.


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About the author

Endurance Arthur

Partner and Solicitor

Partner and solicitor in the medical negligence department and a member of the Law Society's Clinical Negligence Panel