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Care home briefing 159 – Serious untoward incidents: a lesson from Southern Health

Following a Care Quality Commission (CQC) inspection report published in April 2016, Southern Health NHS Foundation Trust came to national attention for deficits in its handling of serious untoward incidents.

The majority of providers have effective systems in place to record, review and remedy potential failings. However, the quality of process can vary and the Southern Health case serves to provide a useful insight into the issues.

Southern Health did have a system of review in place for classifying, investigating and acting upon untoward incidents. It is a system mirrored in most NHS Trusts (developed in conjunction with guidance from the National Patient Safety Agency). It comprised an electronic incident report, and an initial/immediate review of the incident involving categorisation and a decision upon whether a more in-depth root causes analysis investigation is warranted. Where as part of this process any care/service delivery failures are identified, recommendations are made for improvement.

Prior to the death of Connor Sparrowhawk on 4 July 2013 in one of Southern Health’s inpatient short-term learning disability treatment units, the Trust had largely received a clean bill of health from the CQC and relevant local authority, following inspections in 2012.

Connor who was 18 when he died and affected by learning disability and epilepsy, was admitted into the unit in March 2013. At the time of his death in July 2013 he was on 15 minute observations whilst in the bath (something he liked to do over a period of several hours). Connor was discovered 15 minutes into his bath on 3 July 2013 having drowned following a seizure. An initial management review was undertaken though it is unclear as to whether a wider investigation was recommended at this stage.

The CQC undertook a routine inspection in September 2013, determining that the service required improvement though they did not refer to wider governance arrangements, concentrating upon specific issues relating to the delivery of care in the service more generally.

In November 2013 the Trust engaged an independent agency to undertake a review into Connor’s death. The report was published in February 2014 and found Connor’s death to have been preventable for want of proper assessment and management of his epilepsy which had led to an under appreciation of the risks affecting Connor and particularly the need for him to be observed whilst bathing.

The conclusions of this report led to a more concentrated focus upon the Trust’s post-incident process. NHS England and the Local Safeguarding Board commissioned a joint report from a firm of auditors seeking to examine the Trust’s arrangements for reviewing and responding to serious untoward incidents. This latter report was published on 15 December 2015 (some two months after the inquest returned a verdict of death caused or contributed to by neglect). It found there were deficiencies within the Trust’s systems. The report examined data spanning the preceding four years and concluded that there were discrepancies in the consistency and quality of reports and a failure to evidence that the Trust had an effective system of identifying and remedying deficits in care.

Following the audit’s publication the CQC undertook a targeted inspection on this point in January 2016 and repeated the failings identified within the audit report, issuing a Notice of Improvement regarding governance arrangements. The details of the January CQC inspection were reported in April 2016 leading to the very considerable and critical media coverage regarding care provision at Southern Health.

The lessons arising from this are relevant to all those registered with and regulated by the CQC:

  • Firstly, an effective system of review and remedy should serve to identify and correct defective systems leading to improved outcomes for those in your care. The Trust in this case was not able to evidence that the recommendations had been acted upon.
  • Secondly, and if it was not so before, post-incident process is likely to become an increasingly important part of the CQC inspection. The Fundamental Standards, upon which registered providers are judged, provide that good governance must underpin regulated services. In particular the CQC requires ‘systems to check on the quality and safety of care [which] must help the service improve and reduce any risk to your health, safety and welfare.’
  • Thirdly, providers have a statutory responsibility to comply with the duty of candour. This broadly provides that where a person receiving a service has come to harm as a result of a failing on the provider’s part, that person must be notified by way written of apology. Effective systems of review and remedy serve to highlight potential deficiencies in care, enabling service providers to comply with this important duty.
  • Fourthly, an effective system of review is something that all regulators will look for, including Her Majesty’s Coroner. The coroner has the power to write Preventing Future Deaths reports where, during the course of an investigation, it becomes apparent to the coroner that there may be shortcomings in the system that could conceivably put lives at risk. These reports are published and may carry with them significant reputational consequences. Early review and improvement serve to reduce (if not entirely eliminate) the need for the coroner to make such reports.
  • Finally a timely response, recognition and remedy of potential deficits in care, approached in an open and transparent way (involving family from the outset), can reduce the impact of litigation, the need for regulatory censure and the associated damage.

NHS England updated its guidance entitled ‘Serious Incident Framework’ in March 2015, which sets out in detail the expectations required of the NHS as regards this issue. Whether or not you are an NHS provider, it is recommended that you consider this guidance and evaluate your own post-incident operating systems with these observations in mind.


This briefing is for guidance purposes only. RadcliffesLeBrasseur LLP accepts no responsibility or liability whatsoever for any action taken or not taken in relation to this note and recommends that appropriate legal advice be taken having regard to a client's own particular circumstances.

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