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  1. ITV Report

NHS Trust told to make 'urgent and significant' improvements to care

An NHS Trust, which was heavily criticised for "a string of failings" when a vulnerable 18-year-old drowned in a bath while in its care, has been told it needs to make 'urgent and significant' improvements.

The Care Quality Commission (CQC) has told Southern Health NHS Foundation Trust that it had failed to learn from previous mistakes.

Connor Sparrowhawk died at a treatment unit run by Southern Health NHS Foundation Trust. Credit: JusticeforLB/PA Wire

In October, a jury inquest ruled that neglect contributed to the death of Connor Sparrowhawk, who drowned after an epileptic seizure at Slade House in Headington, Oxfordshire, in 2013.

The learning disability unit, run by Southern, has since shut down.

CQC inspectors visited the Trust in January as part of an inspection and found "long-standing risks to patients."

The CQC said it has now issued a warning notice "requiring the trust to improve its governance arrangements to ensure robust investigation and learning from incidents and deaths, to reduce future risks to patients".

The CQC will publish its full report in late April.

We found long-standing risks to patients, arising from the physical environment, that had not been dealt with effectively.

The trust's internal governance arrangements to learn from serious incidents or investigations were not good enough, meaning that opportunities to minimise further risks to patients were lost.

It is only now, following our latest inspection, and in response to the warning notice, that the trust has taken action and has identified further action that it will take to improve safety at Kingsley ward, Melbury Lodge and Evenlode in Buckinghamshire.

– Dr Paul Lelliott, CQC deputy chief inspector of hospitals

NHS Improvement said it intends to take further regulatory action at the trust to ensure urgent patient safety improvements are made.

Southern Health's chief executive said the Trust is taking the CQC's concerns 'extremely seriously'. Credit: http://www.southernhealth.nhs.uk

Katrina Percy, chief executive of Southern Health, admitted "we have a lot of work to do to fully address recent concerns raised about the trust".

Good progress has been made, however we accept that the CQC feels that in some areas we have not acted swiftly enough. My main priority is, and always has been, the safety of our patients.

We take the CQC's concerns extremely seriously and have taken a number of further actions.

I want to reassure our patients and their families that I, and the board, remain completely focused on tackling these concerns as quickly as possible.

– Katrina Percy, chief executive of Southern Health

Luciana Berger, Labour's shadow minister for mental health, said she would raise the issue when Parliament resumes next week, adding: "It is extremely worrying that the trust's leadership has not taken the appropriate action to improve patient safety."