In recent years, there has been an increasing recognition that the way in which the NHS investigates and learns from instances of avoidable harm and death is extremely variable and often poor. This is an issue that has been identified time and time again in major national inquiries, from Sir Ian Kennedy’s report into children’s cardiac surgery at Bristol in 20011, the Mid Staffordshire report in 20132, the Morecambe Bay report in March 20153 and more recently, the Mazars report4, which looked at the deaths of people with learning disabilities who came into contact with the Southern Health trust between April 2011 and March 2015.
The Mazars report was commissioned following the tragic death of 18-year-old Connor Sparrowhawk5. Connor, who had a learning disability and epilepsy, died in 2013 while receiving care at an assessment and treatment centre run by Southern Health NHS Foundation Trust. The report identified serious failings in how the trust recorded and investigated deaths and highlighted that certain groups of patients, including people with a learning disability, were far less likely to have their deaths investigated by the trust.