17th December 2015

Today sees the publication of the ‘Review of Mental Health and Learning Disability Deaths at Southern Health NHS Foundation Trust April 2011 – March 2015’. The review followed the preventable death of Connor Sparrowhawk in July 2013 and was commissioned by NHS England. This long awaited report is an indictment of the Trusts practices and amongst its key findings are:

  • There was no systematic management and oversight of the reporting of deaths and the investigations that follow;
  • 64% of investigations did not involve the family;
  • The Trust held comprehensive information relating to deaths of its service-users but failed to use it.
  • There were was a lack of leadership, focus and time spent in the Trust on reporting and investigating unexpected deaths;
  • Despite the Trust’s Board receiving representations from Coroners that the quality of procedures surrounding SIRIs (that is, Serious Incidents Requiring Investigation) was inadequate, no effective action was taken;
  • Learning from deaths of service users could not be demonstrated.

Deborah Coles, co-director of INQUEST, said:

“NHS England cannot ignore the scandal that is the failure to properly report and investigate deaths of some of society’s most vulnerable people in the care of the state. Successive governments have been repeatedly warned that the investigation system is not fit for purpose. INQUEST’s casework shows that this is a systemic problem and not isolated to one rogue trust. The public needs to know whether these same failings are replicated elsewhere. This damning report must now prompt a national inquiry into mental health and learning disability deaths. Patients and their families deserve nothing less.

The disturbing findings of this report were only uncovered because of the tireless fight for the truth by the family of Connor Sparrowhawk and the Justice for LB campaign. What if Connor had no family to speak up on his behalf? Would any of this have come into the public domain?”

Connor’s mother, Dr Sara Ryan, said:

“This is a very dark moment in the history of the NHS. The review provides evidence that certain people's lives (and deaths) are discounted in a systematic way with no care or regard. Katrina Percy, and the Southern Health Board, should step down immediately, and the Secretary of State needs to act now to examine the extent to which these findings are replicated in other Trusts across the country.”

Charlotte Haworth Hird, family solicitor said:

“We have now written to the Secretary of State for Health, Jeremy Hunt, setting out his legal responsibility to ensure that all of those deaths are investigated, including with the involvement of families and that meaningful action is taken. We have asked him to take steps to assure himself, and the public, that other mental health trusts are not also failing in their duties to report and investigate the deaths of those in their care. We hope to receive a response within the next few weeks.”

INQUEST has been working with the family of Connor Sparrowhawk since July 2013.The family is represented by INQUEST Lawyers Group member Charlotte Haworth Hird of Bindmans Solicitors.


Notes to editors:

On Wednesday 11 February, in parliament, INQUEST launched a report Deaths in Mental Health Detention: An investigation framework fit for purpose? The report is based on INQUEST’s work with families of those who have died in mental health settings and related policy work. It identifies three key themes:

  1. The number of deaths and issues relating to their reporting and monitoring.
    2. The lack of an independent system of pre-inquest investigation as compared to other deaths in detention.
    3. The lack of a robust mechanism for ensuring post-death accountability and learning.

It documents concerns about the lack of a properly independent investigation system unlike deaths in prison and police custody which are independently investigated pre-inquest and the consistent failure by most Trusts to ensure the meaningful involvement of families in investigations.Ultimately, it highlights the lack of effective public scrutiny of deaths in mental health detention that frustrates the ability of NHS organisations to learn and make fundamental changes to policy and practice to protect mental health in-patients and prevent further fatalities and argues for urgent change to policy and practice. 

On 23rd February the Equality and Human Rights Commission published their report of their Inquiry into non-natural deaths in detention of adults with mental health conditions, 2010 – 2013. In November 2014 INQUEST organised a Family Listening Day that was designed to help the Equality and Human Rights Commission gather evidence from the families of adults with mental health conditions who had died in detention.The EHRC published the report of the Listening Day and it can be downloaded here: