Re: Summer 2016 | Page 53

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 51