NHS England published an independent report into the deaths of people with a learning disability or mental health problem at Southern Health NHS Foundation Trust and highlighted a system-wide response.
The report was commissioned by NHS England (South) following the death of Connor Sparrowhawk in July 2013 in a unit in Oxford run by Southern Health NHS Foundation Trust.
Both Southern Health NHS Foundation Trust and the clinical commissioning groups (CCGs) that commission services from them have accepted the recommendations.
- Many investigations were of poor quality and took too long to complete.
- There was a lack of leadership, focus and sufficient time spent in the Trust on carefully reporting and investigating deaths.
- There was a lack of family involvement in investigations after a death.
- Opportunities for the Trust to learn and improve were missed.
Of the 1,454 deaths recorded at the Trust during this period, 722 were categorised as unexpected by the Trust. Of these 540 were reviewed and 272 unexpected deaths received a significant investigation.