NHS – Please Learn from your Mistakes!

George Bernard Shaw once said “Success does not consist in never making mistakes but in never making the same one a second time.” Mistakes should be seen as an opportunity to improve.

However according to a report obtained by the BBC, one of England’s largest mental health and learning disability providers has failed to investigate the unexplained deaths of more than 1,000 mental health and learning disability patients.

The initial investigation was prompted following the death of 18 year old Connor Sparrowhawk in 2013. Connor, who suffered from learning disabilities and autism, drowned in the bath whilst he was a patient at a Unit operated by Southern Health NHS Foundation Trust. A Jury Inquest found that neglect contributed to Connor’s death.

The resulting report found that, between April 2011 and March 2015, almost 10,306 patients had died whilst under the care of the Trust. Of these, 1,454 were unexpected. Inexplicably, the Trust categorised only 272 deaths as “critical incidents”, of which only 13% were subject to a Serious Incident Investigation. For patients older than 65 with mental health problems, only 0.03% of deaths were investigated. Sadly, even when investigations were carried out, they were of a poor quality, extremely late and often contained careless and distressing errors.

The report is very critical of the Trust’s senior leadership team, which repeatedly failed to act upon warnings from Coroners that their investigations were inadequate. Although the Trust now accepts that their reporting has not always been good enough, they have serious concerns about the evidence, which they intend to challenge.

The issues raised within this report are not unique to Southern NHS Foundation Trust. It cannot be denied that patients with learning disabilities continue to experience delays in diagnosis and poor care. It has been found that 1,200 deaths of people with learning disabilities could have been avoided. It is hoped that this report will send shockwaves through the NHS and prompt real and effective improvement and change. NHS England must learn lessons from the report and encourage a culture of transparency among all heath care agencies to prevent further avoidable deaths. Only then will patients with learning disabilities receive the healthcare that they deserve.