Intended for healthcare professionals


Troubled mental health trust is still putting patients at risk, warns CQC

BMJ 2016; 353 doi: (Published 29 April 2016) Cite this as: BMJ 2016;353:i2483
  1. Gareth Iacobucci
  1. The BMJ

A mental health trust in England that was criticised for failing to properly investigate the unexpected deaths of more than 1000 people between 2011 and 2015 is continuing to put patients at risk, the healthcare regulator has warned.

The warning from the Care Quality Commission came after an inspection it carried out at Southern Health NHS Foundation Trust found that the trust had failed to adequately deal with serious concerns about the way it reported and investigated deaths of patients with mental health illness and learning disabilities.1

Jeremy Hunt, the health secretary, ordered the inspection after an independent inquiry found that a “failure of leadership” at the trust had led to the deaths of patients and that the trust had failed to consistently and properly engage families in investigations into the death of their relatives.2

The trust’s chairman, Mike Petter, resigned on 28 April ahead of the CQC’s report, as did one of the trust’s public governors, Mark Aspinall.

The CQC’s team, which inspected the trust over four days in January 2016, found that it had failed to put in place robust governance arrangements to investigate incidents, including deaths, which meant that opportunities had been missed to learn from these incidents and reduce the likelihood of similar events occurring in the future.

In addition, effective arrangements had not been put in place to identify, record, or respond to concerns about safety raised by patients, their carers, staff, or the regulator itself.

The inspection team also identified serious concerns about the safety of patients with mental health problems and learning disabilities in some of the locations inspected and cited a lack of action taken to tackle known risks in the physical environment.

The trust has been under intense scrutiny since a report was commissioned in 2013 in response to the death of Connor Sparrowhawk, an 18 year old patient in a Southern Health hospital in Oxford who drowned in a bath after an epileptic seizure.3 An independent investigation later found that his death had been preventable, and an inquest in October 2015 ruled that the trust’s neglect had contributed to the death.

The CQC’s inspectors reported improvements to the environment in the child and adolescent mental health inpatient and forensic services and in the extent to which children and adolescents were involved in developing their plans of care. But they said that overall the trust was failing to manage and mitigate risk in a timely and effective way.

The CQC said that it was too early for inspectors to judge the effectiveness of new procedures introduced to improve assurance and that it would carry out a further inspection in due course.

Paul Lelliott, the CQC’s deputy chief inspector of hospitals and lead on mental health, said, “Our inspectors found that the quality of the incident reports and initial management assessments, conducted both before and after the introduction of the new procedures, varied considerably.

“We found that in spite of the best efforts of the staff, the key risks and actions to address them were not driving the senior leadership or board agenda. It is clear that the trust had still missed opportunities to learn from adverse incidents and to take action to reduce the chance of similar events happening in the future.”


View Abstract