NHS England will today publish the Mazars report on Southern Health NHS Foundation Trust. It will be available on the NHS England website later today at https://www.england.nhs.uk/south/our-work/ind-invest-reports/. I want to update the House on the action that the NHS will be taking in response.
The report describes, as I set out to the House on 10th December (HC Deb, Col 1141-2), 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. The report found that there had been no effective, systematic management and oversight of the reporting of deaths and the investigations that follow.
I am determined that we learn the lessons of this report, and use it to help build a culture in which failings in care form the basis for learning for organisations and for the system as a whole.
As a first step, I am announcing a number of measures today to address both the local issues at Southern Health NHS Foundation Trust and the systemic issues raised in the report:
- The Care Quality Commission will undertake a focused inspection of Southern Healthcare early in the new year, looking in particular at the Trust’s approach to the investigation of deaths. As part of this inspection, the CQC will assess the Trust’s progress in implementing the action plan required by Monitor and in making the improvements required during their last inspection, published in February of this year.
- Avoidable mortality – understanding, action and improvement. The report reinforces the point that we need to do more across providers to understand and tackle the problem of avoidable mortality. Bruce Keogh and Mike Durkin are therefore writing to Medical Directors to describe the offer of help to providers (the mortality audit tool, case-note review methodology and reiterating the government’s commitment to delivering medical examiners) setting out how to use the audit tool to supply data to support understanding and improvement.
- Learning Disability and mortality. The Learning Disability mortality review will support improvement by acting as a repository for anonymised reports pertaining to people with learning disabilities from a variety of sources, in particular anonymised copies of Serious Case Reviews and Ombudsman Reports. This project will start in January 2016.
- The Care Quality Commission will also be undertaking a wider review into the investigation of deaths in a sample of all types of NHS trust (acute, mental health and community trusts) in different parts of the country. As part of this review, we will assess whether opportunities for prevention of death have been missed, for example by late diagnosis of physical health problems.
I will continue to update the House on progress in each of these areas. I will place a copy of the report in the Library of both Houses once it has been published by NHS England.
This statement has also been made in the House of Lords: