Southern Health NHS Foundation Trust

Andrew Smith Excerpts

Wednesday 8th June 2016 Westminster Hall

[Suella Fernandes]

I thank my hon. Friend for highlighting the problems communicated to her by families, which echo and reflect the precise concerns about which the families sitting in the Public Gallery feel strongly. They emphasise that this is not an isolated issue. This is something that we all need to take seriously.

The Mazars report is the next chapter in this story. At the request of Connor’s family, NHS England commissioned an independent report into the deaths of people with learning disabilities or mental health problems while under Southern Health’s care. The report reviewed the deaths of people in receipt of care from mental health and learning disability services in the trust between April 2011 and March 2015. The report sought to establish the extent of unexpected deaths in those services and to identify issues that needed further investigation.

The report was published in December 2015, and its main findings included, first, that many investigations into deaths were of “poor quality” and took too long to complete. Secondly:

“There was a lack of leadership, focus and sufficient time spent in the Trust on carefully reporting and investigating…deaths”.

Thirdly, there was a lack of family involvement in investigations after a death and, fourthly, opportunities for the trust to learn and improve were missed.

Of the 1,454 deaths recorded at the trust during the period under investigation, 722 were categorised by the trust as unexpected. Of those, the review looked at 540 and found that only 272 unexpected deaths received a significant investigation. The report did not specify how many investigations there should have been, but it drew attention to the limited number of deaths that were investigated in different categories. The trust has questioned the use of some of those figures, but the picture painted overall was one of inconsistent standards for investigations, raising the worrying prospect that an unspecified number of deaths may not have been investigated properly. The question of whether there may have been other preventable deaths like that of Connor Sparrowhawk could not be definitively answered, which has led to a great deal of concern among the trust’s patients and something of a breakdown in confidence. Understandably, people want to know that they or their loved ones will be safe in the care of Southern Health. Those whose relatives have died while under the trust’s care need reassurance that the investigations were properly conducted and that the deaths were not also the result of avoidable errors.

My constituent Richard West is one of those relatives. His son, David, died in 2013, and he has been seeking answers from the trust ever since. At times, the handling of his case has been very poor indeed. Mr West, a former detective and policeman, says that he was ignored and was even told by a representative of the trust that the deaths of patients in its care were “like an airline losing baggage.” I know from speaking to other families that others have experienced similarly insensitive treatment.

The Mazars report contained serious and specific criticisms of the trust and its management. In particular, it levelled criticism at the board itself for the failures. It found that

“there has been a lack of leadership, focus and sufficient time spent on reporting and investigating unexpected deaths of Mental Health and Learning Disability service users at all levels of the Trust including at the Trust Board.”

[Mr Andrew Smith (Oxford East) (Lab)]

I applaud the hon. Lady on securing this debate and on her excellent speech. In just about any other organisation, such a searing indictment of the board and, by implication, its executives would have resulted in their resigning. Is she surprised that they did not simply stand down and accept responsibility, as they should have?

[Suella Fernandes]

There is a lot of pressure from the public, patients and families for people to step down, and the resignation of the chairman of the board is a reflection of the seriousness with which Southern Health takes this issue.

The report continued:

“Due to a lack of strategic focus relating to mortality and to the relatively small numbers of deaths in comparison with total reported safety incidents this has resulted in deaths having little prominence at Board level… There are a number of facets to this poor leadership…: a failure to consistently improve the quality of investigations and of the subsequent reports; a lack of Board challenge to the systems and processes around the investigation of deaths…; a lack of a consistent corporate focus on death reflected in Board reports which are inconsistent over time and which centre only on a small part of the available data; an ad hoc and inadequate approach to involving families and carers in investigations; a lack of focus on deaths amongst the health and social care services caring for people with a Learning Disability; limited information presented at Board and sub-committee level relating to deaths in these groups…; and a lack of attention to key performance indicators…indicating considerable delays in completing…investigations.”

The report also found:

“There was no effective systematic management and oversight in reporting deaths and the investigations that follow… The Trust could not demonstrate a comprehensive, systematic approach to learning from deaths”.

In what I consider one of its most damning findings, the Mazars report also found evidence of repeated warnings being ignored:

“Despite the Board being informed on a number of occasions, including in representation from Coroners, that the quality of the…reporting…and standard of investigation was inadequate no effective action was taken to improve investigations”.

The report also stated:

“Despite the Trust having comprehensive data relating to deaths of its service users it has failed to use it effectively to understand mortality and issues relating to deaths of its Mental Health or Learning Disability service users.”

By any measure, those criticisms were immensely serious and required a robust response.

Following the report’s publication, my right hon. Friend the Secretary of State for Health expressed his determination to learn the lessons of the report and set out a number of measures to address the issues raised, including a focused inspection by the Care Quality Commission looking in particular at the trust’s approach to the investigation of deaths. As part of that inspection, the CQC was asked to assess the trust’s progress on implementing the action plan required by NHS Improvement and on making the improvements required by its last inspection, published in February 2015. Separately, the CQC was also asked to undertake a wider review of the investigation of deaths in a sample of all types of NHS trusts in different parts of the country. That is particularly important because we need to know whether the problems and failings at Southern Health are exceptional outliers or whether there is a similar problem in other parts of the country.

The trust accepted the findings of the Mazars report and apologised unreservedly for the failings identified. NHS Improvement set out in January 2016 its plans to provide assistance to the trust to ensure that it delivers on plans to implement the agreed improvements, which include the appointment of a new improvement director and the taking of advice from independent experts. All those measures were agreed by the trust’s management, and in January we had a letter from the chief executive officer setting that out.

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[Mr Andrew Smith (Oxford East) (Lab)]

I congratulate the hon. Member for Fareham (Suella Fernandes) on securing this vital debate and on her work with the all-party group on Hampshire and Isle of Wight. Everything that has come out or been dragged out since the tragically avoidable death of Connor Sparrowhawk, “Laughing Boy”, has highlighted the severe failings of Southern Health and the wider questions they raise about the treatment of learning-disabled people in the NHS. The facts that have emerged are awful beyond belief and are a shocking indictment of the leadership of the Southern Health trust and the appalling neglect of the most basic care needs and human rights of learning-disabled people.

As the hon. Lady said, we all owe enormous thanks to the courage and determination of Connor’s mother, Sara Ryan, and her family, as well as the other families of those who have died and suffered. Without them, there was a real risk that the hideous truth of neglect at Southern Health might not have been fully exposed. Connor’s family and other families have been let down so badly and shamefully by Southern Health, which did not share information that the family had a right to. The family were treated as the enemy at Connor’s inquest and did not even receive an apology until Southern Health was directly pressed to give one. Even today, as Sara went for mediation with Southern Health on her human rights case, it had not released background papers, as it was supposed to have done.

The Mazars report happened only because of the determination and persistence of Connor’s family. As we have heard, the failings it exposed were shocking beyond belief and have been confirmed by the CQC reports. It is important to remember some of the hideous statistics that the hon. Lady quoted; we should remember that each one is a human life. Of 10,306 deaths, 722 were categorised as unexpected, of which only 272, or 37%, were investigated as a critical incident. A lower proportion—30%—of deaths in adult mental services were investigated. Appallingly, less than 1% of deaths in learning disability services were investigated. Liaison with families was appalling, with 64% of investigations not involving the family.

I will quote what the My Life, My Choice charity from my constituency said in a letter yesterday to the new chair of Southern Health. It is a charity of learning-disabled people, for learning-disabled people. This is how things look from the perspective of people with learning disabilities. It said:

“You suggested that the Mazars report was not very important, or not true. We think it is a very important report. Our members are very worried about people with learning disabilities dying, and their deaths not being properly looked into. We know from Connor’s case that the truth is not always told, so investigations need to happen. Our members are scared because people with learning disabilities do not get the same standard of healthcare as everybody else. The Mazars report told us that if we die, our deaths will not be taken seriously.”

Someone has to take responsibility for what happened. To the families and to the public, it is unbelievable that the chief executive and medical director of Southern Health are still in post. We all understand that due process has to be followed, but nearly three years on from Connor’s death, we must ask: how long will it take before those responsible are properly held to account? That is important not just to atone for a wrong; it is crucial because of the signal it sends to others responsible for the care of learning-disabled and other vulnerable patients. It is crucial in re-establishing public confidence that those leading the provision of care are responsible and are held responsible for their actions.

I look forward to the Minister’s response to this debate. With Sara Ryan I met the Secretary of State, and I have talked and corresponded with the Minister. I know that they too are both concerned to see matters put right at the trust, and to apply the lessons more generally in the healthcare system.

[Nicola Blackwood (Oxford West and Abingdon) (Con)]

The right hon. Gentleman is making a powerful speech. His point that no one, no matter how vulnerable, should feel fear when they go into our health services is something that should give us all pause for thought in this Chamber. But it is not only about accountability in this case; it is also about making sure that those who are watching us as we go through the process know that an independent, verifiable process will be put in place so that nothing like this can ever happen again, not only at Southern Health but throughout our mental health services.

[Mr Smith]

I very much agree with the hon. Lady, my neighbour and friend, on that important point. I look forward to the Minister’s response as to what the independent oversight will be to ensure security in future.

It will be helpful if the Minister can update us on progress in relation both to the Southern Health trust and to wider concerns in the NHS, and if he can say when he expects the CQC to publish its opinion on the trust’s response to its warning notice, with the possibility of enforcement action being taken. Will he also say when he expects the Government to be in a position to make a definitive statement on the action they will take on the conclusion of the Care Quality Commission’s wider investigation into deaths throughout the NHS? It is an enormously important issue to get right.

We all have to learn from these appalling events. We have to apply the lessons and put in place procedures and the culture so that learning-disabled people and others receive the care, treatment and respect that they deserve, and so that they can be confident that they will get that. An NHS that truly fulfils its duty of care, in which Southern Health so lamentably failed, is the only thing that can come close to a fitting memorial for Connor Sparrowhawk.

[Mr David Hanson (in the Chair)]

We can be more relaxed about the two remaining speakers because a Member who indicated that they wished to speak has now left.

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[Alistair Burt]

My hon. Friend makes her own point about a conversation I was not part of. I am sure people will read what she has to say.

As I have already set out, a clear and robust process is being taken forward by the interim chair to review the capability of the board and to take any necessary action. My hon. Friend the Member for Fareham has called for far-reaching changes. I ask that we await the conclusions of the review and look for the right balance to be struck between continuity and stability to ensure that the trust is able to deliver what it has promised. Wholesale change could introduce further delays to making progress on such work.

Recent media reports have suggested that the trust might be split up. I repeat that the priority now is to ensure safe and effective care in the present and in the future for the population served by Southern Health. NHS Improvement is working with the trust to explore all available options.

Members have also asked why the trust has not been prosecuted for historic safety breaches. I am aware of the allegations of historic health and safety breaches made by a former health and safety advisor to the trust, who has also briefed CQC about such concerns. I share the concerns of all those who are asking why it has taken so long to get a grip on the issues. CQC did indeed identify safety concerns back in October 2014 and has provided an assessment of safety in its most recent report. However, it is unforgivable that patients have continued to be exposed to unnecessary risk while the trust has dragged its feet in resolving the problems.

I understand that CQC has now reviewed evidence gathered during the most recent inspections and additional information obtained from the trust and other public bodies, including the Health and Safety Executive. CQC’s review has identified further lines of inquiry, which it plans to complete as quickly as possible in order to inform a decision on prosecution one way or the other.

[Mr Andrew Smith]

Is it not the case that following the gathering of that further evidence and, indeed, of other leaked reports of what Southern Health knew at an earlier stage, which had not previously been apparent, the police are now reviewing the case for prosecution?

[Alistair Burt]

Genuinely, I am unaware of that. The police may review evidence at any time. If CQC has certain evidence that it wishes to take to the police for prosecution, that is a matter for it. I understand the processes that people would want to go through. It is important for me to offer reassurance that those processes are in place, and that things that for too long have been swept under the carpet are open for examination, which I understand to be the case.

Let me deal with the question of a public inquiry. Ministers face many calls for inquiries, and it is important for public inquiries to be considered only where other available investigatory mechanisms would not be sufficient. Public inquiries are rare events. I argue that the processes now being followed by NHS Improvement and CQC are the best way to put right the safety and governance issues at Southern Health. That does not rule out the dissemination of wider learning from this case through NHS Improvement or, where appropriate, the holding to account of individuals via professional regulation or normal performance management routes.

It is right and proper that we should ask such questions. We can perhaps examine whether the system would have responded in the same way had the trust been an acute trust, as I mentioned earlier. I am passionate about improving the care and outcomes for people with mental illness or learning disabilities by ensuring that all aspects of healthcare for people, whatever the issue that has brought them into the care of the NHS and others, are given equal priority with physical health. That must include regulation.

Let me now deal with the point made by my hon. Friend the Member for Oxford West and Abingdon (Nicola Blackwood). As I have indicated, what I have observed over the past year has worried me. That is to say, there seems to be greater tolerance of when things go wrong in mental health than in acute services. We need to ask ourselves why it has taken so long to resolve those difficulties and to reach the regulatory decisions that are now starting to take effect.

I will therefore be looking at the matter with NHS Improvement, to consider both the effectiveness and the timeliness of regulatory interventions in mental health and learning disability services. I am keen to bring independent leadership into that work, alongside NHS Improvement. A task-and-report group will do a piece of work specifically on that.

Let me name the other places that have upset me during the course of the year. In Hull, there has been a problem with in-patient beds and an inability on the part of the NHS to make decisions about it for more than three years. There was the case of Matthew Garnett, the young man with autism in the wrong place; I could not get information on him for weeks, because of the failure of the NHS to provide what I needed. There are the problems in Tottenham with new mental health facilities, similar to what happened in York, at Bootham Park—how that was closed, and the inability of people to handle it correctly. That is a whole series of cases in which I think things could have been done better. The response has not been good enough. An inquiry into one thing is not sufficient, and the processes are in place to deal with that. Looking at the whole range of why such things happen is really important, and that work is now underway.