Issue - meetings

Report of the Chair of the Health Overview and Scrutiny Panel relating to the recently published Mazars report commissioned by NHS England, attached.

NOTE: Appendix 3 of the report has been updated following the meeting of the Panel to reflect information omitted in error from the original table.

The Panel considered the report of the Chair of the Health Overview and Scrutiny Panel reviewing the recently published Mazars report commissioned by NHS England to investigate unexpected deaths of service users of Southern Health NHS Foundation Trust Mental Health or Learning Disability services from April 2011 to March 2015. The report highlighted a number of actions for the Trust, commissioners and regulators.

The Chair of the HOSP introduced the key findings and issues arising from the Mazars report:

(i)  that there was a lack of leadership, focus and sufficient time spent in the Trust on carefully reporting and investigating unexpected deaths of Mental Health and Learning Disability service users.

(ii)  That despite the Board being informed on a number of occasions, including representation from Coroners, that the quality of the Serious Incidents Requiring Investigation reporting processes and standard of investigation was inadequate; no effective action was taken to improve investigations during the review period.

(iii)  That 30% of all deaths in Adult Mental Health services were investigated as Critical Incident Reviews or Serious Incidents Requiring Investigation, less than 1% of deaths in Learning Disability services were investigated as Critical Incident Reviews or Serious Incident Requiring Investigation and 0.3% of all deaths of Older People in Mental Health services were investigated as Serious Incident Requiring Investigation.

(iv)  In terms of deaths ‘categorised as unexpected’ within Adult Mental Health services, 60% of all unexpected deaths were investigated as Critical Incident Reviews or Serious Incidents Requiring Investigation; in Learning Disability only 4% of all unexpected deaths were investigated as Critical Incident Reviews or Serious Incidents Requiring Investigation and in Older Peoples’ Mental Health services, 13% were investigated as a Serious Incidents Requiring Investigation.

(v)  From the review of the evidence, too few deaths were investigated in Learning Disability and Older People Mental Health services.  When an investigation did occur, the report identified the overall poor quality of these investigations and of the subsequent reports.

(vi)  That there was no effective systematic management and oversight of the reporting of deaths and the investigations that followed.

(vii)  Timeliness of investigations was a major concern – taking on average of nearly 10 months from an incident to ‘closing’ a Serious Incident Requiring Investigation (SIRI) relating to deaths.

(viii)  The Trust could not demonstrate a comprehensive, systematic approach to learning from deaths.

(ix)  The involvement of families and carers had been limited - 64% of investigations did not involve the family.

(x)  Initial management assessments and investigations did not involve other service providers where this would have been appropriate.

(xi)  Despite the Trust having comprehensive data relating to deaths of its service users, it had failed to use it effectively to understand mortality and issues relating to deaths of its Mental Health or Learning Disability service users.

(xii)  Commissioners had a role in demanding better information relating to deaths and using it to seek improvement.

It was stated that the Hampshire Health and Adult Social Care Scrutiny Committee were to discuss the report at their meeting  ...  view the full minutes text for item 29