Jeremy Hunt, the health secretary, is facing calls for a nationwide inquiry into the deaths of highly vulnerable patients in NHS care after it emerged that just one in seven such fatalities in hospitals in England have been investigated.



Data released to the Guardian under freedom of information (FOI) laws show that hospitals in England have investigated just 222 out of 1,638 deaths of patients with learning disabilities since 2011.

Even among deaths they classed as unexpected, hospitals inquired into just over a third. Only 137 (35%) of the 397 deaths in that category were the subject of an investigation, despite longstanding concerns that these patients receive poorer care and are at higher risk of dying while in hospital.

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“The findings from this investigation are very concerning,” said Prof Mike Richards, England’s chief inspector of hospitals. “We’re keen to work with the Guardian to look at the new information in more detail. This will help us to plan the review that CQC [Care Quality Commission] is already committed to doing.”

The data has provoked serious unease as it appears to show that recently exposed failings at the Southern Health NHS trust, in the south of England, are widespread. A report by the audit firm Mazars, commissioned by the Department of Health, showed that at that trust just four of 93 unexpected deaths among people with a learning disability were looked into. Trusts are meant to examine and learn from unexpected deaths under tougher NHS-wide patient safety rules introduced after the Mid Staffs scandal to reduce the risk of repeated mistakes. An expected death is one that follows a period of illness which has been identified as terminal and where there is no active intervention to prolong life while an unexpected death is one where these conditions don’t apply.

Jan Tregelles, chief executive of the charity Mencap, said: “The Guardian’s wider findings about trusts’ investigation of deaths will leave many families questioning whether their loved one’s death in NHS care should have been properly investigated. One thousand two hundred people with a learning disability are dying avoidably in the NHS every year. After the Mazars review, we know many deaths are not being properly investigated.”

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The Guardian sent FoI requests to 53 mental health trusts in England that provide services for people with learning disabilities, either as in patients or outpatients. Of those, 37 provided data for all patients.

Only four of the 32 trusts where patients with learning disabilities died (including both expected and unexpected) investigated all of them. But Somerset Partnership NHS foundation trust; Northamptonshire Healthcare NHS Foundation Trust; Bradford District NHS Foundation Trust; Rotherham, Doncaster and South Humber NHS Trust; Sussex Partnership NHS Foundation Trust; and South Essex Partnership University NHS Foundation Trust looked into none of the 146, 63, 53, 28, 25 and 21 deaths that occurred in their care respectively since 2011. None of the deaths reported by Somerset, Northamptonshire or Sussex were recorded as unexpected.

Leicestershire Partnership NHS trust investigated one of its 116 deaths, while Dorset Healthcare University NHS foundation trust inquired into two of the 97 it had.

The figures for unexpected deaths are even more concerning. They showed that 397 such deaths occurred at 24 different trusts, but 11 of them have investigated fewer than half.

Derbyshire Healthcare NHS foundation trust and Sheffield Health and Social Care NHS foundation trust both investigated just one of the 21 unexpected deaths they each had. Leicestershire Partnership NHS Trust looked into just one of the 13 it had, and Tees, Esk and Wear Valleys NHS Foundation Trust investigated seven of its 65 such deaths. Pennine Care NHS Foundation Trust looked into a single death of its 10, although the trust said that the other nine unexpected deaths were subsequently found to be from natural causes or related to poor physical health.

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Five of the 37 trusts which provided data for all patients reported no deaths and 13 said they had had no unexpected deaths.

Southern Health NHS foundation trust reported by far the highest total number of deaths at 396. It investigated 51 of 67 unexpected deaths but explained that there were different levels of investigation. Some deaths receive an initial management review usually carried in within 48 hours of the death while others receive a full root cause analysis investigation which is more rigorous. Other trusts also operate different levels of investigation.

The number of unexpected deaths reported for Southern Health in the FOI data (67) is lower than that reported in the government-commissioned inquiry 93 because it included people being attended by a social care team.

A spokesperson for the trust said: “Whilst we accept that the quality, timeliness and family involvement in investigations should have been better, the trust is not an outlier with regards to mortality data and we believe we investigated the deaths where we had a responsibility to do so.”

The CQC, the NHS care regulator, has already said it will undertake a focused inspection of Southern Health early in 2016, which will look specifically at how and whether the trust investigates deaths.

“We will also be doing a wider review into the investigation of deaths of people with learning disabilities in mental health and acute trusts in different parts of the country. As part of this review, we will assess whether opportunities for prevention of death have been missed, for example, by late diagnosis of physical health problems,” a spokeswoman said.

A spokesperson for the Department of Health said NHS trusts should look into all unexpected deaths. “As the government’s response to Southern Health made clear, it is important that the NHS properly investigates unexpected deaths to learn lessons and improve care. That’s why the secretary of state has announced an investigation by the CQC into how deaths are investigated in all types of trusts. [NHS England medical director] Prof Sir Bruce Keogh has also written to all NHS hospitals asking them for an assessment of their avoidable mortality to drive learning in the system,” the spokesperson said.

A government-funded inquiry that reported in 2013 found that an estimated 1,238 children and adults with learning disabilities die every year in England as a result of receiving poor care from the NHS. The three-year confidential inquiry into such deaths followed a series of reports by Mencap and other groups concerned at what they said was the unequal standard of healthcare received by such patients.

Researchers from Bristol University concluded that 37% of the deaths among those with a learning disability were avoidable. Compared with the general population, men with a learning disability died on average 13 years earlier, while women with a learning disability died 20 years earlier, they found.

An NHS England spokesperson said: “We in the NHS are determined to improve care for all our patients. NHS England recently wrote to every trust in the country asking them to review and report avoidable mortality rates.

“This places England as the first ever country to monitor the extent of avoidable deaths, and will provide a basis on to which to learn, improve and ensure the NHS is the safest health care system in the world.”

• This is a corrected version of an article first published on 21 December 2015 and taken down on 23 December 2015. Some of the data was incorrect in the earlier version. This version is based on data from a fresh set of FoI responses.

• This article was amended on 2 May 2015. As a result of an editing error, an earlier version transposed the figures for deaths of patients with learning difficulties at Rotherham, Doncaster and South Humber NHS Trust and at Bradford District NHS Foundation Trust. Rotherham had 28 deaths, not 53.