Yesterday I posted a story about a disabled man who was given a 'Do Not Rescusitate' notice by Doctors because he was..... disabled.
This is a 'Guardian' article about the scandal at "The Southern Healthcare Trust", where deaths of vulnerable people in the Trusts care have not been properly investigated;
The Guardian 9/12/15.
An NHS hospital trust failed to properly investigate the deaths of more than 1,000 patients with learning disabilities or mental health problems over four years, an independent inquiry has found.
A leaked copy of the inquiry’s report severely criticises a “failure of leadership” at Southern health NHS foundation trust and accuses senior managers of not looking into and learning from deaths.
NHS England commissioned Mazars, an audit firm, to examine the 10,306 patient deaths which occurred at the trust between April 2011 and March 2010.
While most of those deaths were expected, 1,454 were unexpected.
The Mazars report, obtained by the BBC, concludes that failures by the trust’s board and senior executives meant that no “effective” management of deaths or investigations took place and there was a lack of “effective focus or leadership from the board”, the BBC said.
The Mazars inquiry team found that when trust board members did ask questions, executives reassured them that investigations were thorough. However, the report concluded: “This is contrary to our findings.”
It also found that the culture of the NHS trust, which is led by chief executive Katrina Percy, “results in lost learning, a lack of transparency when care problems occur, as well as assurance to families that a death was not avoidable and has been properly investigated”.
Of the 1,454 unexpected deaths, the trust regarded 272 as critical incidents but classed only 195 of them – or one in seven – as a serious incident that needed to be investigated.
But while it looked into 30% of the deaths among adults with mental health problems, it did so with only 1% of those with learning disabilities and 0.3% of over-65s with mental health problems.
Patients with a learning disability died at an average age of 56, which is seven years earlier than the usual life expectancy.
“These are shocking revelations that if proven, reveal deep failures at Southern health NHS foundation trust,” said Luciana Berger, Labour’s shadow minister for mental health.
“For there to have been so many unexpected deaths in one trust is of deep concern itself, but for so many of those deaths not to have been investigated is extremely alarming. It raises serious questions about the leadership and culture of care at the trust.”
NHS England ordered the inquiry after Connor Sparrowhawk an 18-year-old with learning disabilities, drowned in a bath at the trust’s Slade House unit after suffering an epileptic seizure. Coroners had also criticised the trust at inquests for producing reports into deaths that were inadequate or very late, but 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, the Mazars report found.
Sara Ryan, Sparrowhawk’s mother, told the BBC: “There is no reason why in 2015 a report like this should come out. It’s a total scandal. It just sickens me.”
The trust provides community services, mental health, learning disability and social care services to about 45,000 people in Hampshire, Dorset, Wiltshire, Oxfordshire and Buckinghamshire.
The Mazars report said that the trust was unable to show that it had a good system in place for learning from deaths and did not use effectively the extensive data it collected on deaths.
It also found that the trust looked into too few deaths involving either those with a learning disability or older people with mental health problems and failed to involve relatives in almost two out of three of the investigations it did undertake.
Southern accepted that its response to patient deaths was not good enough but denied that its death rate was higher than would be expected.
“We fully accept that our reporting processes following a patient death have not always been good enough. We have taken considerable measures to strengthen our investigation and learning from deaths including increased monitoring and scrutiny,” it said in a statement.
“We would stress the draft report contains no evidence of more deaths than expected in the last four years of people with mental health needs or learning disabilities for the size and age of the population we serve.”
The trust has “serious concerns” about the way Mazars had
interpreted the evidence. It added that while it had “had one or more contacts” with the patients in the previous 12 months, “in almost all cases referred to in the report, the trust was not the main provider of care”.
Jan Tregelles, the chief executive of the charity Mencap, said: “Twelve hundred people with a learning disability are dying avoidably in the NHS every year. This is a national scandal.”
All such deaths need to be properly analysed so that other avoidable deaths can be prevented, she added.
Neil Harris
(a don't stop till you drop production)
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