Side lined families and a failure to learn from past mistakes?

BBC News obtained a draft report which claimed a major NHS trust had failed to investigate the unexpected deaths of more than 1000 patients with mental health conditions and/or learning difficulties since 2011. This, in turn, has prompted the Health Secretary, Jeremy Hunt, to announce a nationwide review of how patient deaths within the NHS are monitored and reviewed.

The investigation which prompted the wider review was commissioned by NHS England and has looked into deaths at the Southern Health NHS Foundation Trust, between April 2011 and March 2015.

The investigations in to the trust were ordered after the death of an 18 year old, Connor Sparrowhawk. Connor suffered from epilepsy and experience seizures. He drowned in a bath following a seizure whilst in a Southern Health Hospital in Oxford.

The report’s critical findings highlight that, in two thirds of cases, there was no family involvement in investigations and that information gathered about these unexpected deaths was not acted upon to improve care - potentially repeating a cycle of failure in care of vulnerable patients.

Both Southern Health NHS Foundation Trust and NHS England say that, once the final report is published, they will act on all the issues raised.

As we have commented previously, there are many areas of NHS and private medical care where the general culture of care and standards of clinical expertise are very good. However, in our experience as specialists representing patients and families in cases of clinical negligence, care can still vary tremendously from location to location – particularly for vulnerable patients.

Many victims of clinical negligence are motivated to make a claim to ensure that lessons are learnt from mistakes and to get a better understanding of what went wrong and why. We are sure the Southern Health draft report will resonate with many of victims of clinical negligence – and not necessarily for the right reasons. We can only hope that it will prove to be a catalyst to improves not only in the Southern Health Foundation Trust but also in other areas of the NHS.