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Southern Health criticised for putting 'patients at risk' Southern Health criticised for putting 'patients at risk'
(about 1 hour later)
The NHS mental health trust which ran a care unit where a teenager drowned in a bath is "continuing to put patients at risk", inspectors have said.The NHS mental health trust which ran a care unit where a teenager drowned in a bath is "continuing to put patients at risk", inspectors have said.
Southern Health failed to adopt safe bathing guidelines for two-and-a-half years after Connor Sparrowhawk died following an epileptic seizure in 2013.Southern Health failed to adopt safe bathing guidelines for two-and-a-half years after Connor Sparrowhawk died following an epileptic seizure in 2013.
His unsupervised death led to a report into hundreds of unexplained deaths.His unsupervised death led to a report into hundreds of unexplained deaths.
Trust chairman Mike Petter resigned on Thursday ahead of the publication of the Care Quality Commission's report.Trust chairman Mike Petter resigned on Thursday ahead of the publication of the Care Quality Commission's report.
He said he was stepping down "to allow new board leadership to take forward the improvements".He said he was stepping down "to allow new board leadership to take forward the improvements".
Southern Health provides services in Hampshire, Dorset, Wiltshire, Oxfordshire and Buckinghamshire.
Patients jumped off hospital roofPatients jumped off hospital roof
Read more updates on this story and more from Oxfordshire
Following Mr Petter's departure, one of the trust's 13 public governors Mark Aspinall, also resigned.Following Mr Petter's departure, one of the trust's 13 public governors Mark Aspinall, also resigned.
In his statement, the public governor for Oxfordshire and Buckinghamshire said he had been disappointed by the "apparent lack of drive and determination" by some governors in dealing with troubles faced by the trust.In his statement, the public governor for Oxfordshire and Buckinghamshire said he had been disappointed by the "apparent lack of drive and determination" by some governors in dealing with troubles faced by the trust.
The CQC's inspection in January was ordered after an investigation looked at all deaths at the trust between April 2011 and March 2015 and found hundreds had not been investigated properly. The CQC - the independent regulator for health and social care in England - launched an inspection of Southern Health in January after it was found hundreds of deaths at the trust between April 2011 and March 2015 had not been investigated properly.
Now the watchdog has said the trust has still not done enough to reduce "environmental risks" and condemned a low roof at a Winchester site that patients could climb onto and ligature points across its sites.Now the watchdog has said the trust has still not done enough to reduce "environmental risks" and condemned a low roof at a Winchester site that patients could climb onto and ligature points across its sites.
'Missed opportunities''Missed opportunities'
The report revealed there were eight occasions where patients had climbed onto the roof between 2010 and 2015, as well as two in February - one of which involved a patient leaving the ward and then leaving the country.The report revealed there were eight occasions where patients had climbed onto the roof between 2010 and 2015, as well as two in February - one of which involved a patient leaving the ward and then leaving the country.
Health service regulator NHS Improvement has said it would impose management changes at the trust if progress was not made to address the CQC's concerns.Health service regulator NHS Improvement has said it would impose management changes at the trust if progress was not made to address the CQC's concerns.
Dr Paul Lelliott, deputy chief inspector of hospitals, said that, despite staff efforts, risks to patients were "not driving the senior leadership or board agenda".Dr Paul Lelliott, deputy chief inspector of hospitals, said that, despite staff efforts, risks to patients were "not driving the senior leadership or board agenda".
He said: "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.
"I am concerned that the leadership of this trust shows little evidence of being proactive in identifying risk to the people it cares or of taking action to address that risk.""I am concerned that the leadership of this trust shows little evidence of being proactive in identifying risk to the people it cares or of taking action to address that risk."
He added that a new process to monitor serious incidents and deaths had been introduced by the trust in December, but it was too early to gauge its impact.He added that a new process to monitor serious incidents and deaths had been introduced by the trust in December, but it was too early to gauge its impact.
A leaked 2012 review found staff did not feel Slade House, an in-patient unit for people with learning difficulties in Oxford, was safe and that it was dirty and difficult to track the care of patients at the unit. A 2012 review leaked earlier this week found staff did not feel Slade House, an in-patient unit for people with learning difficulties in Oxford where Connor Sparrowhawk died, was safe and that it was dirty and difficult to track the care of patients at the unit.
An inquest jury found in October that neglect contributed to Connor's death at the unit.An inquest jury found in October that neglect contributed to Connor's death at the unit.
Dr Sara Ryan, his mother, described seeing the 2012 report as "shocking and harrowing" and said she would be asking police to open an investigation. Dr Sara Ryan, his mother, earlier described seeing the 2012 report as "shocking and harrowing" and said she would be asking police to open an investigation.
"It is a national scandal. It shows that certain people in our society aren't given the same healthcare treatment as other people," she said.
"How much more failing do we have to have evidence for before the chief executive and the rest of the board are removed?"
Connor's stepfather, Richard Huggins, said: "If we'd known anything of the things we now know, we wouldn't have admitted Connor to that unit.Connor's stepfather, Richard Huggins, said: "If we'd known anything of the things we now know, we wouldn't have admitted Connor to that unit.
"We have found out in the three years since it happened so many things that are deeply disturbing, not just about Connor but about many other people. What I find particularly disturbing about this case is that, if Connor hadn't died, none of this would have come out. "We have found out in the three years since it happened so many things that are deeply disturbing, not just about Connor but about many other people. What I find particularly disturbing about this case is that, if Connor hadn't died, none of this would have come out."
"What's so disappointing about the regulatory regime is that it's entirely reactive. It relies on people, families, careers, concerned individuals to keep going. This trust tried to bury what happened to Connor and if we had not been there for Connor... they would have probably have been able to do that. Dr Ryan added: "There's such a gap between what they say they do and what they actually do and this is what the CQC has uncovered."
"I think the regulatory regime is too close to the organisations it regulates and there's too much credence given to statements like we will learn and we will improve."
Dr Ryan added: "There's such a gap between what they say they and what they actually do and this is what the CQC has actually uncovered.
"I think there are lots of really good staff working at Southern Health who are really constrained by the leadership. They've just got this toxic set of people who don't understand how to learn."
'Hamstrung''Hamstrung'
In his resignation letter Mr Aspinall said: "It has become a source of frustration that there are governors who appear apathetic or intransigent and that the corollary of this is that the council seems either weak or unable to act. In his resignation letter Mr Aspinall said: "I feel hamstrung by the constant barrage of critical news that keeps hitting the trust. Unable to move forward but not seemingly able to correct the mistakes either."
"I know this is not necessarily true and there has been a desire from many governors to help drive the trust forward.
"I feel hamstrung by the constant barrage of critical news that keeps hitting the trust. Unable to move forward but not seemingly able to correct the mistakes either."
Of the trust's council of governors, he said: "I had hoped that we would be able to work well together to deliver for our patients and communities but, sadly, there is more drum-banging, soap-boxing and agenda-pushing taking place than anything else.
"It is no secret that I think there have been failures of leadership within the trust, that we cannot hope to recover until those are addressed, and that the council of governors is, as part of that leadership, equally culpable for the situation we are in."
Trust chief executive Katrina Percy said the CQC's findings sent "a clear message to the leadership... that more improvements must be delivered and as rapidly as possible".Trust chief executive Katrina Percy said the CQC's findings sent "a clear message to the leadership... that more improvements must be delivered and as rapidly as possible".
She added: "We will continue to share regular updates on progress publicly to demonstrate improvement and help re-build trust in our services."She added: "We will continue to share regular updates on progress publicly to demonstrate improvement and help re-build trust in our services."
Southern Health provides services in Hampshire, Dorset, Wiltshire, Oxfordshire and Buckinghamshire. Liberal Democrat MP and former health minister Norman Lamb called for further resignations.
He said: "The board has to take responsibility for this, so I think the whole board has to be held to account but also, I think the chief executive has to go.
"How many opportunities, chances do they need to recognise the absolute importance of this?"