Southern Health NHS Foundation Trust still not doing enough to protect people in its care

Published: 29 April 2016 Page last updated: 12 May 2022

The Care Quality Commission (CQC) today publishes the findings of a short-notice, focussed inspection of Southern Health NHS Foundation Trust, conducted over four days in January 2016.

This inspection took place following the publication of an independent review (the Mazars report) that described a number of serious concerns about the way the Trust reported and investigated deaths, particularly of people using its mental health and learning disabilities services. It also identified that the Trust had failed to consistently and properly engage families in investigations into the death of their relatives.

In response to the publication of the Mazars report, the Secretary of State requested that CQC review the Trust’s governance arrangements and approach to identifying, reporting, monitoring, investigating and learning from deaths, and the Trust’s progress in implementing the action plan required by Monitor (now NHS Improvement) to address this.

In addition, CQC wanted to check whether the Trust had made the improvements required as a result of its previous comprehensive inspection in October 2014 and the focussed inspection of the learning disability services at the Ridgeway Centre, High Wycombe carried out in August 2015.

The CQC report published today details the findings of a team of 22 inspectors, which included several mental health professionals as specialist advisors. The inspection team spoke with patients, carers, staff, the Trust Board and whistle blowers. In addition, they reviewed patient records, serious incident reports, medication charts and policy and procedures including those relating to complaints and governance. They found that:

  • The Trust had not put in place robust governance arrangements to investigate incidents, including deaths. As a result, opportunities had been missed to learn from these incidents and to take action to reduce the likelihood of similar events happening in the future.
  • Effective arrangements had not been put in place to identify, record or respond to concerns about patient safety raised by patients, their carers, staff or by the CQC. The Trust had also failed to identify, record or respond effectively to staff who expressed concerns about their competence to carry out their roles.
  • Inspectors had serious concerns about the safety of patients with mental health problems and learning disabilities in some of the locations inspected. Action had not been taken to address known risks from the physical environment. For example, CQC had identified concerns relating to ligature risks in acute inpatient mental health and learning disabilities services in January 2014, October 2014 and August 2015. During the January 2016 CQC found that the Trust had still failed to make sufficient changes to address these risks with many potential ligature anchor points identified at one location. Immediately following the inspection, CQC issued a warning notice requiring Trust to take immediate action to ensure the safety of patients at Evenlode, Oxfordshire and Kingsley ward at Melbury Lodge.
  • Overall, the Trust’s governance arrangements did not facilitate effective, proactive, timely management of risk. Where action was taken by the Trust to mitigate risk, this was delayed and mainly done in response to concerns raised by the CQC.

Inspectors did find that some improvements had been made to the environment in the child and adolescent mental health inpatient and forensic services. Also, the Trust had improved the extent to which children and young people were involved in developing their plans of care. Improvements had been made to support patients better who were acutely unwell in community services in Southampton, and to ensuring that patients did not experience multiple transfers between teams when they needed to be admitted or discharged from hospital.

At the time of the inspection the Trust was in the process of introducing new procedures with the potential to provide it with more robust oversight and assurance. However, it was too early for inspectors to judge whether these would have the desired effect

The full report is available.

Dr Paul Lelliott, Deputy Chief Inspector of Hospitals and Lead for Mental Health, said:

“Since the failings identified in the Mazars report, this Trust has, rightly, been under intense scrutiny. In December 2015 it introduced a new system for reporting and investigating incidents, including deaths. It is too early to gauge the effectiveness of the new process. However, our inspectors found that the quality of the incident reports and initial management assessments, conducted both before and after the introduction of the new procedures, varied considerably.

“We found that in spite of the best efforts of the staff, the key risks and actions to address them were not driving the senior leadership or board agenda. It is clear that the Trust had still missed opportunities to learn from adverse incidents and to take action to reduce the chance of similar events happening in the future.

“For example, although the Trust had identified that when people did not attend appointments, they could be at high risk of harm, there was no clear guidance for staff working in community mental health teams about what they should do when a patient does not attend an appointment.

“While all clinical staff had been informed of the new system for reporting incidents and patient deaths, we found on our inspection in January 2016 that some staff were still unsure of when and how to involve families, and it was not always clear what discussions or communications had taken place to involve families.

“We were also very concerned about the lack of action taken to address risk to people posed by the physical environment in which they were being cared for. For example, we asked the Trust to take immediate action to ensure patients who access the garden at Melbury Lodge do not climb onto the low roof. There have been a number of incidents of patients injuring themselves, some seriously, by falling from the roof, and of patients detained under the Mental Health Act absconding by that route. We issued a warning notice immediately following this inspection requiring the Trust that they must make improvements to ensure people’s safety. We also told the Trust that they must put in place effective governance arrangements to ensure that patient safety incidents are investigated and learned from.

“I am concerned that the leadership of this Trust shows little evidence of being proactive in identifying risk to the people it cares for or of taking action to address that risk before concerns are raised by external bodies. Along with partners including NHS Improvement and NHS England, we will be monitoring progress extremely closely. We will be looking not only for evidence of improvements, but for evidence that this Board is actively planning to protect patients in their care from the risk of harm.”

The Trust has supplied an action plan setting out the steps it will take to address the concerns identified in the warning notice and CQC will be monitoring the Trust closely with regards to its progress. A further inspection will take place in due course to check that the required improvements have been made and are being sustained.


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Find out more

Read our reports about Southern Health NHS Foundation Trust.

We found that in spite of the best efforts of the staff, the key risks and actions to address them were not driving the senior leadership or board agenda.

Dr Paul Lelliott, Deputy Chief Inspector of Hospitals and Lead for Mental Health

About the Care Quality Commission

The Care Quality Commission (CQC) is the independent regulator of health and social care in England.

We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve.

We monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and we publish what we find to help people choose care.