In March 2017 the National Quality Board published National Guidance on Learning from Deaths, part of which included a requirement on all NHS Trusts to report specific mortality data. In line with the principles of openness and transparency, Southern Health has reported these figures nationally, and is also making the information available today through our board papers and on our website.
While all NHS Trusts are required to report on this data, it is important to note that there is no nationally agreed system for mental health trusts to do so, in the way that there is for acute trusts. In Southern Health all deaths are classified as Serious Incidents Requiring Investigation (SIRI), and then go through various levels of investigation before a Corporate Panel ratification process takes place, which give a final impact grading to determine if they can be considered preventable or not.
Between April and September 2017 (quarters one and two) 30 deaths were reported as serious incidents, and of those five have been classed as being preventable. Between October and December 2017 (quarter three), 12 deaths were reported as serious incidents, and either have been or are being investigated before going through to the Corporate Panel ratification process.
Chief Executive, Nick Broughton said, “It is never acceptable for a person to die in a preventable way whilst under our care. We have various processes in place for learning from serious incidents, and sharing that learning with colleagues, and although I do believe these to be effective, while we continue to report deaths as preventable, these are not robust enough.
“Any death in our services is a harrowing experience for the family members, carers, and those staff who cared for the person, but particularly so when there is a requirement to ask lots of questions, investigate, and then identify where we may have gone wrong. It is incredibly difficult to personally acknowledge these mistakes but also vital that we understand them and learn from them. I know everyone working for the Trust will support me in saying that we must continue to develop our working practices to ensure that no patient ever dies in a way that could have been prevented.”