This report was a response to the some of the failings identified following the tragic death of Conor Sparrowhawk whilst under the care of Southern Healthcare. Sadly, his case is not the only instance of patients being let down by an NHS that continues to fear openness and transparency. This is despite the introduction of the duty of candour and a widespread acknowledgement of the need to become better at learning.
Changing the culture of an organisation is one of the most difficult things to do, especially when pressures to reduce costs are put above measures to improve services. Psychiatrists know too well the impact that can have on patients and their families – lack of beds and access to mental health services risk the safety and wellbeing of patients. Even in death, the lack of parity between physical and mental health continues to be evident.
We echo the Inquiry’s call for commissioners to take note of the conclusions of this report. We know the issues identified in the report exist across the health care system and we will insist that similar standards are put in place to encourage learning from unexpected deaths in these sectors, especially given recent concerns over avoidable deaths in those with drug and alcohol problems.
As a Royal College of Psychiatrists we also know that systems alone will never be enough. Managers and individual healthcare professionals must act to ensure a culture of learning and transparency is not only embedded across the health service but also valued as a core part of how patients are cared for.
No one benefits from a culture that hides behind legalities or seeks to blame individuals who are often working under very difficult circumstances. Communicating with the bereaved is a specific skill and we hope that managers will make sure their staff are properly trained and supported to be openly compassionate and caring when having those essential first meetings between relatives and staff following a death.
It is right and proper that opportunity is taken to improve how we learn from unexpected deaths, and in particular how we ensure that families are not left feeling isolated or ignored. But we must not lose sight of the fact that the biggest reasons for avoidable deaths are already known - and we must redouble our efforts to address these. Improving the physical health of those with mental illness and/or learning disability is a major priority for this College, given the incontrovertible evidence of premature mortality in our patients. Learning from unexpected deaths is part of this, but we take the opportunity to emphasise that we already know the largest contributors to early mortality – obesity, lack of exercise, poor diet, hypertension, cancer and heart disease, many of which are smoking related.