All fatalities in England to be investigated after Connor Sparrowhawk case highlights poor care

This article is more than 1 year old

This article is more than 1 year old

The NHS is to start investigating the deaths of more than 100,0000 mental health patients a year in a drive to cut the number of fatalities linked to poor care.

England’s 54 specialist mental health trusts have been told to start looking into every death in an effort to learn from mistakes.

In future they should more fully investigate cases in which the patient may have received poor or unsafe care, especially if they had bipolar disorder or an eating disorder.

The first guidance to trusts on the subject has been drawn up by the Royal College of Psychiatrists and is being backed by NHS England. It is meant to end the existing ad hoc system whereby different trusts examine smaller or larger numbers of deaths.

“We hope that this will improve care, save lives and reassure friends and family who have lost a loved one that if they have concerns, they will be acted on [by the trust which was providing care],” said Dr Adrian James, the college’s registrar.

Mental health trusts’ failure to look into patients’ deaths became an issue in 2015 when it emerged that Southern health trust had not examined the death of about 1,000 patients with autism or learning disabilities.

Its failures were highlighted by the poor care it gave to Connor Sparrowhawk, an 18-year-old with epilepsy and autism, who drowned in a bath in the trust’s Slade House facility in Oxford in 2013 after his doctor made 39 different errors.

Under the guidance, any one of four “red flags” will automatically trigger an in-depth inquiry by a senior trust doctor who was not involved in caring for the patient who died.

They include relatives or staff having voiced unease about the deceased’s care and any patient having recently had psychosis or an eating disorder.

An investigation will also be recommended when a patient had recently been treated in a psychiatric ward or been under the care of a crisis team or home treatment team when they died.

Louis Appleby, a professor of mental health at Manchester University and the director of the university’s National Confidential Inquiry into Suicide and Safety in Mental Health, welcomed the move.

“This is about two things: learning from what goes wrong and the public accountability of public services,” he said.

“Families can be hugely frustrated by the repetition of ‘lessons will be learned’ after a tragedy. Here is an attempt, a practical process, to make sure that happens.

“Large studies are one way but examining individual cases can turn up crucial details – gaps in care that can be put right for the safety of others.”

The Guardian disclosed in March that at least 271 mental health patients in England and Wales had died since 2012 after errors by NHS trusts.

Dr Panchu Xavier, the associate medical director of learning reviews at Mersey Care NHS trust, said that his trust – one of the 11 involved in piloting the guidance – uses it to look at 350-400 deaths a month.

As a result it has recently increased the number it then subjects to review from three or four to eight or 10 a month.

“The college’s guidance has been extremely effective. We found that the red flag system highlighted all the most pressing cases and is saving us hundreds of hours of staff time.”

Barbara Keeley, the shadow cabinet minister for mental health, said: “For families of people with mental ill-health, this guidance will provide vital reassurance that the deaths of some of the country’s most vulnerable patients will be investigated and that these heartbreaking cases can be stopped from happening in the future.”

Caroline Dinenage, the care minister, said: “Each preventable death is a tragedy and we must learn from each one.

“This new guidance will equip trusts with the tools to more quickly identify areas of improvement, provide more support for families and implement changes to better care for people with severe mental health conditions.”

• This article was amended on 27 November 2018. An earlier version said that “an investigation will also be mandatory when a patient had recently been treated in a psychiatric ward or been under the care of a crisis team or home treatment team when they died.” In fact, the guidance sets out that an investigation is recommended, but is not mandatory. This has been corrected.