Southern Health NHS Trust deaths public investigation call

The deaths of David West and Marion Munns were among those considered in the report

An NHS trust should face a public investigation over patient deaths and "deeply regrettable" failures, a report has found.

The deaths of four Southern Health NHS Foundation Trust patients, between 2012 and 2015, were considered in the report commissioned by NHS Improvement.

It found leadership was "sadly lacking" at the organisation at the time.

Southern Health said it had "made significant changes" since the period covered by the report.

A previous report, published in 2015, found only 272 of 722 unexpected deaths were properly investigated by the trust.

The latest independent report, carried out by Nigel Pascoe QC, looked into the deaths of:

• Robert Small, 28, of Fareham, Hampshire, who had a history of depression and died on 17 September 2012

• David West, 28, of Southampton, who had a history of mental health problems and died on 21 October 2013

• Edward Hartley, 18, who died following an epileptic seizure at home in Hampshire on 28 May 2014 while being looked after by a carer

• Marion Munns, 74, of Southampton, who died on 12 November 2015 after suffering a mental health breakdown

Mr Pascoe said there had been "significant, serious and deeply regrettable failures" by the trust as well as "disturbing insensitivity and a serious lack of proper communication" with family members.

Robert Small (left) was 28 when he died in 2012, while Edward Hartley died in 2014, aged 18

He added those failures had "caused real and long-lasting harm".

"What has been presented to me is a truly deplorable and unacceptable saga, which cannot be attributed simply to a lack of resources," Mr Pascoe said.

"At significant and important times, leadership was sadly lacking and too often that contributed to a systemic culture of delay."

He did acknowledge there had been some "individual acts of compassion" by staff and said recent responses from the trust had "sought to address concerns appropriately and with understanding".

However, he said its failings "must be made plain and deprecated in the greater public interest" and "must never be repeated".

"I recommend a limited public investigation that is specific and focused in nature," he said.

'Payments to families'

He recommended it should include the circumstances of the death of Mr Hartley, complaint handling, communication and liaison with patients' families, and the way practices and procedures, particularly risk assessments, were carried out.

"Only then can those concerned have the chance to consider that, at long last, justice has been done," he added.

He also concluded, in all four cases, ex-gratia payments should be made to the families but added: "No sum of money can alleviate the distress which has been caused."

A fifth death was included in the review - that of Jo Deering, who died in 2011 - but her sister, Maureen Rickman, said it had failed to answer her questions so her death was withdrawn from the report.

Jane Hartley, Mr Hartley's mother, said: "We are pleased that we are going to get some more scrutiny.

"This hasn't happened to our satisfaction before, but this should have been dealt with efficiently and effectively at the time and it wasn't so, six years on, I have got to relive all of this and I don't see any fairness in that."

In January 2020, the Care Quality Commission rated the trust "good" following "significant improvement".

Southern Health's chief executive Dr Nick Broughton said it had already made changes "as a direct result of contributions from families and learning from past failings".

He said: "This report reinforces our own view: that at times the trust's response to families' understandable concerns added to their distress at an already difficult time.

"This is completely unacceptable: I am profoundly sorry."

Southern Health runs services in Hampshire.

Southern Health timeline

April 2012 - Teresa Colvin dies after being found unconscious at Woodhaven Adult Mental Health Hospital at Calmore, Hampshire

July 2013 - Connor Sparrowhawk drowns after an epileptic seizure at Oxford unit Slade House

December 2015 - An independent report shows out of 722 unexpected deaths over four years, only 272 were properly investigated

April 2016 - A CQC inspection report says the trust is continuing to put patients at risk

June 2016 - Following a review of the management team, it is announced the trust's boss Katrina Percy is to keep her job

July 2016 - The BBC reveals the trust paid millions of pounds in contracts to companies owned by previous associates of Ms Percy

October 2016 - Ms Percy resigns

December 2016 - A CQC report says investigations into patient deaths are inadequate

August 2017 - A medical tribunal finds a doctor failed to carry out risk assessments for Connor Sparrowhawk

12 September 2017 - Dr Nick Broughton becomes Southern Health's new boss

18 September 2017 - The trust admits breaching health and safety law in the case of Connor Sparrowhawk

November 2017 - The trust admits breaching health and safety law in the case of Theresa Colvin

March 2018 - The trust is fined £950,000 for Mrs Colvin's death and just over £1m for that of Connor Sparrowhawk

January 2020 - The Care Quality Commission rates the trust "good" following "significant improvement"