Independent review of deaths of people with a learning disability or mental health problem in contact with Southern Health NHS Foundation Trust April 2011 to March 2015

Summary

The preventable death of Connor Sparrowhawk in July 2013 led to a number of investigations and enquiries into practice at Southern Health NHS Foundation Trust in whose care he died.

This is a review of all deaths of people in receipt of care from Mental Health and Learning Disability services in the Trust between April 2011 and March 2015. It is not a clinical case review of each service user and we have therefore not tried to identify clinically unavoidable deaths. It does seek to establish the extent of unexpected deaths in Mental Health and Learning Disability services provided by the Trust and to identify any themes, patterns or issues that may need further investigation based on a scope provided by NHS England.

We were asked to benchmark this Trust with other similar organisations where this was possible. In the report, we focus on the responsibilities as they impact on the Trust to report deaths and then to secure the right level of review, enquiry or investigation. However, the responsibility for investigating deaths lies with a number of organisations across the area and we refer to these responsibilities where appropriate.