THE BEREAVED mother of Connor Sparrowhawk has said Southern Health's admission, that their investigations into patient deaths were inadequate, is "not enough." 

Today the Southern Health NHS Foundation Trust accepted that their investigations "needed to be better," after a report found that more than 1,000 patient deaths since 2011 may not have been properly investigated. 

Commissioner NHS England South is conducting the Mazars Report into 1,100 deaths of people with mental health problems and learning disabilities who were helped by the Trust.

According to a leaked document not enough deaths of people with learning disabilities or older people aged over 65 were investigated, the BBC reported last night.

In an updated statement released today, Southern Health NHS Foundation Trust accepted they had failed to meet standards. 

Earlier this year an inquest at Oxford Coroner's Court heard that the death of 18-year-old Connor Sparrowhawk, who drowned in a bath following an epileptic fit at the trust's Slade House unit in Headington, had been 'contributed to by neglect'.

Mr Sparrowhawk's mother Sara Ryan said she read the NHS report about three months ago.

She said: “It was totally shocking. It feels good that it’s all coming out now.

“We are just appalled that they are not accepting the findings. Their statement is not enough, they’ve shown no interest. All they care about is their reputation – they’ve demonstrated that for years.

“We have moved away from even thinking about an apology from this bunch. There should be resignations, the report showed there were failings at board level. It’s a problem that’s bigger than Southern Health.”

She said she had had a “remarkable” reaction to the family’s campaign ‘Justice for LB' (Laughing Boy, Mr Sparrowhawk's online nickname) which has been supported by local leaders like Oxford East MP Andrew Smith.

Deborah Coles, director of the charity Inquest, which has represented Mr Sparrowhawk's family, said: "This report should send shock waves across the NHS. The failure to investigate deaths of some of society's most vulnerable people is a scandal that must be urgently addressed.

"What is so disturbing is that this report only came about because of the tireless fight for the truth by the family of Connor Sparrowhawk. This damning report must now prompt a national inquiry. Their families deserve nothing less."

According to the BBC, deaths of adults with mental health problems were the most likely to be investigated, with 30% of cases examined.

But the figure fell to just 1% for patients with learning disabilities and 0.3% in over-65s with mental health problems.

In nearly two-thirds of investigations there was no family involvement.

The report found investigations were of a poor quality and often extremely late, while there were repeated criticisms from coroners about the timeliness and usefulness of reports provided for inquests by Southern Health.

In an urgent meeting called in the House of Commons this afternoon, health secretary Jeremy Hunt said the findings were "totally and utterly unacceptable."

He pledged to publish Ofsted-style ratings of the quality of care for people with learning disabilities, from next June. 

Jan Tregelles, chief executive of learning disability charity Mencap, said: “1,200 people with a learning disability are dying avoidably in the NHS every year. This is a national scandal.

"Mencap’s 'Death by Indifference' campaign has highlighted the lack of value and lack of priority placed on the lives of people with a learning disability. This is a very real crisis that is happening to people with a learning disability and their families across the UK right now. 

"We remain extremely concerned about the lack of progress on this issue by government and the NHS.”

The report is expected to be made public later this week. 

An NHS England spokesperson said: "We commissioned an independent report because it was clear that there are significant concerns.

"We are determined that, for the sake of past, present and future patients and their families, all the issues should be examined and any lessons clearly identified and acted upon.
 
“The final full independent report will be published as soon as possible, and all the agencies involved stand ready to take appropriate action.”

Southern Health NHS Foundation Trust today said: "The Board has fully accepted that the quality of processes for investigating and reporting a patient death, whilst improving, needed to be better. They had not always been up to the high standards our patients, their families and carers deserve.

“However we have already made substantial improvements in this area over a sustained period of time. 

"These include:

  • Significantly strengthening the Executive oversight of the quality of investigations, ensuring appropriate actions are in place to address any issues identified
  • Setting up a new central investigation team which is working to improve the quality of investigations
  • Launching a new system for reporting and investigating deaths in consultation with our Commissioners to increase monitoring, scrutiny and learning
  • Capturing conclusions of inquests more effectively to identify and act swiftly on areas for improvement

“These issues are not unique to the Trust and we welcome the opportunity to shine a spotlight on this important area. We are engaging with Commissioners to drive improvements across the local health economy.

“Though the Trust continues to challenge the draft report’s interpretation of the evidence, our focus and priority is on continuing to improve the services we provide for our patients.

“When the final report is published by NHS England we will review the recommendations and make any further changes necessary to ensure the processes through which we report, investigate and learn from deaths are of the highest possible standard.

“If you are directly affected by this issue, call this NHS number: 0300 003 0025.”