‘Significant gaps’ in care highlighted in NHS review of deaths
Trust’s chief executive’s unreserved apology to families hit by tragedies
AN INVESTIGATION into a series of deaths under a trust’s care has concluded that sytematic failings led to errors in their care.
NHS England commissioned a review into Southern Health NHS Foundation Trust, into five deaths between 2011 and 2015.
The trust provides services in mental health and learning disabilities.
A report into the second stage of the investigation has since been published, highlighting how ‘significant gaps’ in care occurred during that same time period.
Clerical errors, information not being shared between carers and mistakes with medication were all highlighted.
Ron Shields, chief executive of Southern Health NHS Foundation Trust, said: ‘This second report brings important recommendations to help us provide the best possible care to patients, carers and families. I thank the panel and everyone who contributed.
‘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.
‘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.’
The report concluded that since the deaths, changes have been made to improve the relationship between carers, service users and their families — but these changes ‘have not been universal in their impact’.
It added that the ‘gold standard’ had still not been reached.
Mr Shields added: ‘Making these changes remains our absolute priority and we will now produce a detailed plan to reflect the report’s recommendations, showing where we have already made changes and how we will make the further improvements necessary.’
The report has recommended that Southern Health NHS Foundation Trust strengthens its links with Hampshire Healthwatch, to ensure that the voices of service users, family members and carers are heard.
It has also recommended improvements to the sharing of information between clinicians and that learning is shared more widely throughout the whole organisation, plus additional improvements to monitoring.
Campaigner Geoff Hill, who has been supporting families after the deaths of their loved ones, said: ‘The outcome of the Pascoe Investigation is disappointing but entirely predictable.
‘It fully justifies the decision of the bereaved families and other potential witnesses to withdraw from the process
in February.
‘In the report, again the chief executive of the trust expresses unreserved apologies for the errors, mistakes and distress caused by the incidents involving the bereaved families.
‘Yet, to the best of my knowledge and belief, he has not contacted any of them directly.’
There is much more for us to do to get things right first time, every time. Ron Shields