Learning, candour and accountability
NHS England's commissioned review looked at all mental health and learning disability deaths at Southern Health NHS Foundation Trust between April 2011 and March 2015.
The report identified a number of failings in the way the trust recorded and investigated deaths and highlighted that certain groups of patients including people with a learning disability and older people receiving mental health care were far less likely to have their deaths investigated by the trust.
The report focused on five key areas: Involvement of families and carers:
- Identification and reporting
- Decision to review or investigate
- Reviews and investigations
- Governance and learning
The report’s recommendations include:
- Learning from deaths needs much greater priority within the NHS to avoid missing opportunities to improve care.
- Bereaved relatives and carers must receive an honest and caring response from health and social care providers and the NHS should support their right to be meaningfully involved.
- Healthcare providers should have a consistent approach to identifying and reporting the deaths of people using their services and share this information with other services involved in a patient's care.
- There needs to be a clear approach to support healthcare professionals' decisions to review and/or investigate a death, informed by timely access to information.
- Reviews and investigations need to be high quality and focus on system analysis rather than individual errors. Staff should have specialist training and protected time to undertake investigations.
- Greater clarity is needed to support agencies working together to investigate deaths and to identify improvements needed across services and commissioning.
- Learning from reviews and investigations needs to be better disseminated across trusts and other health and social care agencies, ensuring that appropriate actions are implemented and reviewed.
- More work is needed to ensure the deaths of people with a mental health or learning disability diagnosis receive the attention they need.
