Reviews / 2015
Independent review of deaths of people with a learning disability or mental health problem at Southern Health
Mazars · work from 2015 · published 2015
What this was
Review of how Southern Health investigated deaths of people with a learning disability or mental health problem. Most such deaths were not treated as needing a serious investigation.
Why it sits in the hub
It led to the national Learning from Deaths programme. The same gap — whose death counts as something to learn from — is still visible in the Lampard Inquiry's terms of reference.
Findings
Finding 1
Deaths of people with learning disabilities or mental illness were far less likely to be investigated than other deaths.
Recommendations in this hub
Paraphrase of the public recommendations, not the official text.
- 1Partly doneNHS trusts
Investigate deaths of people with a learning disability or mental illness to the same standard as other unexpected deaths.
National Learning from Deaths guidance followed. Practice remains variable.
- 2Partly doneTrust boards
Report those investigations to the board.