The Southern Health NHS Foundation
Trust, which covers Hampshire, Dorset,
Wiltshire, Oxfordshire and Buckinghamshire
and provides services for approximately
45,000 people, has been issued a warning
by the Care Quality Commission (CQC)
that they need to “significantly improve”
the protection of mental health patients in
particular following an inspection in January
of this year. Furthermore, following an
independent report by Mazars last year, it
was also found that there had been a failing
in leadership by the Trust to investigate the
unexplained deaths of hundreds of patients.
The inquest into Connor’s death and the
subsequent focused inspection on the
Southern Health Trust in particular seems
to have opened up a preverbal can of
worms for the NHS as a whole, with
Health Secretary Jeremy Hunt saying in
December 2015 that, as part of the review
of the Southern Health Trust, they would
be assessing “whether opportunities for
prevention of death have been missed.”
Mr Hunt then went further than this by
saying that there is an urgent need “to
improve the investigation of, and learning
from, the estimated 200 avoidable deaths
we have every week across the system”.
Connor’s was one such death. The inquest
found that neglect by the care unit looking
after him contributed to his death in 2013,
when he died after having an epileptic
seizure whilst in the bath, aged just 18
years old.
The figure of 200 avoidable deaths per
week seems startlingly high, especially in
this day and age, but Beverley Dawkins
(who acted as advisor to the report carried
out following Conor’s death) has said that
such a finding may only be “the tip of an
iceberg” and that without proper, ongoing
The figure of 200 avoidable deaths per week seems
startlingly high, especially in this day and age
mortality review we won’t understand the
full scale of the problem.
For those that have lost a loved one in
circumstances that are referred to as
unexplained or a ‘serious incident requiring
investigation’, such quotes by Jeremy
Hunt and Beverley Dawkins may open up
a further depth of pain as the possibility
that their loved one’s death could have
been avoided could be very real. And
unfortunately, that is not necessarily where it
ends for such families. The official enquiry
into the Southern Health Trust which
covered a period from April 2011 to June
2015 found that many deaths were either
not investigated or the quality of those that
were investigated were then described as
“poor” and “much delayed”.
This, in turn, could raise a further question;
could such delays in investigation restrict
the number of claims that could be brought
by the families of those whose deaths could
have been prevented? The Limitation Act of
1980 provides that a person can only bring
a claim for clinical negligence within 3 years
of the negligence occurring or the person’s
knowledge of the negligence. If the said
person were then to die within this limitation
period, their estate would have 3 years from
the date of death to bring a claim. If the
investigations into whether or not a death
was preventable are too much delayed,
there is always a possibility that an action
brought on behalf of the deceased’s estate
could be statute barred if the delay exceeds
the limitation period.
There is a glimmer of hope though in
relation to avoidable deaths. Jeremy Hunt
has outlined a three-point plan to try and
improve this situation. Firstly, as of June
2016, they will bring in ‘Ofsted style’ ratings
for all 209 Clinical Commissioning Group
areas in England. Secondly, the University
of Bristol will carry out a study into the
mortality rates of people with learning
disabilities by NHS Trusts, as the recent
report into the Southern Health Trust shows
that fewer than 1% of deaths of people with
learning disabilities were investigated. And
thirdly that as of next year the Government
will look to publish the number of avoidable
deaths by NHS Trusts.
Whether the inquest into the Southern
Health Trust and this three-point plan being
put forward by the Government will lower
the number of avoidable deaths within the
NHS remains to be seen, but one can at
least hope that the NHS as a whole will try
and learn from their past mistakes.
If you wish to discuss a potential medical
negligence claim on behalf of a deceased
loved one please contact us.
By Jenny Crocker
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