Southern Health inquiry: Trust needs 'continuing reform'

(L-R) David West, Robert Small, Marion Munns, Edward Hartley and Jo Deering died in the care of Southern Health Foundation Trust

A scandal-hit NHS trust "needs continuing reform" despite making recent improvements to its standards of care, a public inquiry has concluded.

An independent review into Southern Health was held after failures were found to have led to five vulnerable patients dying between 2011 and 2015.

The latest report, written by a panel chaired by lawyer Nigel Pascoe QC, said there were still "matters of concern".

The trust reiterated an earlier apology and said it has made improvements.

The panel made 39 recommendations and raised nine learning points to be considered with Southern Health, which provides psychiatric and disability support services to people in Hampshire.

Nigel Pascoe QC led the inquiry into Southern Health NHS Foundation Trust

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

This prompted a second stage to the inquiry that examined current processes, including complaint handling, communication with patients' families, and the way practices, such as risk assessments, were undertaken.

The report concluded there was "evidence of improvement" by the trust "towards increased engagement with service users, carers and family members".

"But these changes have not been universal in their impact and the evidence, taken as a whole, suggests that they have not always happened to the standards expected, or in some cases, at all," the panel said.

"Therefore, the panel is driven to conclude that there is a real need for continuing systematic and practical reform in [Southern Health] to fill significant gaps and resolve difficult issues."

Who are the families?

• Maureen Rickman, sister of Jo Deering, 52, from New Milton, Hampshire, who died in 2011

• Diane Small, mother of Robert Small, 28, from Fareham, Hampshire, who died in 2012

• Richard West, father of David West, 28, from Southampton, who died in 2013

• Ian and Jane Hartley, parents of Edward Hartley, 18, from Wickham, Hampshire, who died in 2014

• Angie Mote and Kim Vella, daughters of Marion Munns, 74, from Southampton, who died in 2015

Bereaved family members were due to take part in the latest inquiry but decided to withdraw before it started after they claimed to have been "misled, misrepresented and bullied" by the NHS.

Maureen Rickman, whose sister Jo Deering died in 2011, said: "It's ridiculous. I'm quite disturbed when I look at what's come out today in relation to deaths because they are not saying what they are going to do.

"They are not even acknowledging what's gone wrong."

The first in a series of reports into Southern Health in 2015 revealed the trust failed to investigate hundreds of deaths. The scandal led to the chief executive and chairman having to resign.

The trust was also fined £2m due to failings in relation to two patients, including 18-year-old Connor Sparrowhawk.

He drowned in a bath following an epileptic seizure while under the care of the trust in Oxfordshire - an area previously covered by the trust.

'Improving services'

Ron Shields, the trust's chief executive, said, it was an "absolute priority" to make changes and will "produce a detailed plan to reflect the report's recommendations".

"On behalf of the trust, I apologise again unreservedly to the families affected by the tragedies of 2011-15 highlighted in Mr Pascoe's first report," he added.

"While we focus on improving services now and in the future, we do not forget or diminish the failings of the past.

"As the report acknowledges, the trust has made significant improvements since then - but we know there is much more for us to do, in partnership with service users and their families, to get things right first time, every time."