A leaked report reveals a major NHS Trust failed to investigate the unexpected deaths of more than 1,000 mental health patients.

NHS England was ordered to report upon the deaths of patients at Southern Health NHS Foundation Trust.

Southern Health NHS Foundation Trust is one of the country’s biggest providers of mental health care, serving around 45,000 patients across the south of England.

The report, which is yet to be formally published, considered the 10,306 deaths which occurred at the Trust between April 2011 and March 2015.

Of these, 1,454 were deemed ‘unexpected’. Despite this, only 195 deaths were judged to be a ‘serious incident requiring investigation’ (SIRI).

An investigation was more likely if an adult with a mental health problem died unexpectedly, with 30% of cases being investigated.

This figure fell to 1% for those with learning disabilities, and 0.3% for over-65s with mental health problems.

“Deeply disturbing”

The NHS England report says that even when an investigation was performed, it would often be late and of a poor standard.

These failings were first brought to light in 2013 after an 18 year old man, who was under the care of a Southern Health hospital in Oxford, suffered an epileptic seizure in the bath and drowned.

His mother said the Trust’s behaviour was “barbaric”. An independent investigation later found that the man’s death could have been prevented.

Beverly Dawkins, who was involved in the NHS England report, said the findings were only “the tip of the iceberg”, adding: “Until there is a proper mortality review we won’t understand the scale of the problem.”

Health Secretary Jeremy Hunt said the government is “profoundly shocked” by the report, while one MP said it was “deeply disturbing.”

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