Medical lawyers call for swift action by trust as report highlights failure to investigate deaths

Health rights lawyers have reacted with dismay to the finding of a report which claims that an NHS Trust has failed to investigate the deaths of more than 1,000 people since 2011.

A leaked copy of a report of an independent inquiry into Southern Health NHS Foundation Trust has revealed that the trust failed to properly investigate the deaths of patients with learning disabilities or mental health problems over a period of four years.

The inquiry was commissioned by NHS England who asked audit firm Mazars, to look at over 10,000 deaths that occurred at the trust between April 2011 and March 2015.


Most of the deaths were found to be expected, but some 1400 were not.  

272 of the deaths were treated as critical incidents, but only 13% of these were treated as serious incidents requiring investigation.

The investigation rate into the deaths of people with learning disabilities as 1%, and for people older than 65 with mental health problems, it was 0.03%.

The report noted that when investigations were carried out they were often late, and of poor quality.  

Families of relatives whose loved ones died who spoke to BBC news say that they feel entirely let down by the failure of the trust to investigate the unexpected deaths of their vulnerable patients.

The report has blamed a ‘failure of leadership’ at the trust which has admitted that its investigation process has not always been good enough, but denies that its death rate was higher than expected.

The inquiry was set up following the death of 18 year-old Connor Sparrowhawk who had learning disabilities and drowned in a bath at one of the trust’s units after suffering an epileptic seizure. An independent investigation said that his death had been preventable.  An inquest jury found that neglect by the trust had contributed to Connor’s death.

Speaking to the BBC Sara Ryan, Sparrowhawk’s mother said: “There is no reason why in 2015 a report like this should come out. It’s a total scandal. It just sickens me.”

The trust is one of the largest mental health trusts in the UK and provides community services, mental health, learning disability and social care services to some 45,000 patients.

Medical negligence partner Suzanne White said of the report.

“The findings of this report are shocking and suggest that the deaths of learning disabled patients and patients with poor mental health are somehow less important or worthy of investigation than those of other people.

“We have acted for many families who feel let down by hospitals who have failed to look after their vulnerable relatives.  These failures often only come to light at the inquest into their loved ones’ deaths and can give a shocking insight into the actions of health staff who have failed in their duty towards vulnerable patients.  

“Coroners are reported to have criticised the standards of the reports provided by Southern health trust, saying that they were delivered late, and were often of a poor standard.  It is vitally important that health trusts gather accurate data about death rates, and use the findings of incident reports to improve their services to vulnerable patients, rather than failing to engage with the challenges that they reveal.

“The most vulnerable patients need the most sensitive and appropriate care possible and it is shocking to discover that a trust that cares for thousands of such patients has let them and their families down so badly.”

The human rights and medical negligence team at Leigh Day is willing and able to help support and advise families. We have expertise in clinical negligence, human rights, inquests and coronial law and can offer PR and media support to families.