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Southern Health : failures to protect patients from harm and the challenges faced to improve safety


    Lucy Crawford considers the recent Care Quality Commission report in relation to Southern Health NHS Foundation Trust, and implications for patient care and safety.

    By Lucy Crawford

I have been reading the regular concerning news reports about Southern Health NHS Foundation Trust, one of the country’s largest mental health trusts, covering Hampshire, Dorset, Wiltshire, Oxfordshire and Buckinghamshire, and the reported failings in patient care.

Southern Health NHS Foundation Trust – The story so far

The issues with Southern Health NHS Foundation Trust seem to have come to a head following the tragic death of Connor Sparrowhawk.  In 2013, aged 18 years, Connor Sparrowhawk was admitted to Slade House – an assessment and treatment unit in Oxfordshire and run by Southern Health.  Connor had autism, a learning disability and epilepsy.  In 2013, his behaviour became more challenging and it was felt Slade House would provide much needed support to the teenager.

On 4th July 2013, he was found unconscious in the bath and very sadly later died.  Post-mortem results showed he had drowned as a result of an epileptic seizure and an inquest ruled that neglect had contributed to his preventable death.

In December 2015 an investigation commissioned by NHS England found that the Trust had failed to properly investigate a large proportion of deaths under their care, and my colleague Simon wrote about this at the time.

Care Quality Commission report

The Care Quality Commission (CQC), an independent regulator for health and social care in England, launched an inspection into Southern Health NHS FT in 2016.  Its report in February 2016 highlighted numerous failings, including serious concerns about patient safety, inadequate arrangements to properly investigate incidents (including deaths), “missed opportunities”, failings in staff training, poor hygiene, poor record keeping and poor communication with families.

The lack of improvement in key areas following previous concern being raised, and the disregard for patient safety is concerning and hundreds of families have been left grieving and wondering if the death’s of their loved ones could have been avoided.

So what next?

Sadly, this is not the only example of poor patient care.  For instance, in 2011 BBC’s Panorama programme exposed abuse of patients with learning disabilities at the Winterbourne View, Gloucestershire.

Again within Southern Health NHS FT, Melbury Lodge, which houses patients with severe mental health concerns, has seen 12 people gain across to their roof and jump off in the last 5 years.  It seems Southern Health it falling woefully short when it comes to managing the risks posed by patients.

Southern Health is coming under intense scrutiny and it has been reported there is ‘blame’ culture appearing, particularly in the more senior leadership roles.   The Chairman has already resigned and there is mounting pressure for the Chief Executive to also stand down.

Whilst there are clearly very severe failings in this Trust, it seems to me the problems go even further.  I and my colleagues have acted for a number of families who have lost loved ones as a result of failings in mental health care, and not limited to this Trust.  Community based treatment and assessment for mental health and learning disabilities is often wholly inadequate and without these provisions, more and more pressure is being placed on these specialist units to deliver higher standards with less and less funding available. It seems standards have been falling short for years and in many ways it is surprising that it is only now the issues are seemingly being tackled.

Monitoring of Southern Health is continuing over the next few months and a further inspection by the CQC will reveal what improvements have been made and what steps still need to be taken to ensure patient safety.

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