The leaked findings of the Mazars report commissioned by NHS England into all deaths at the Southern Health NHS Foundation Trust since April 2011, as revealed by the BBC, are extremely disturbing. We need to see the full report published as soon as possible so that we can begin to appreciate the scale of the problem and what needs to be done.
The most disturbing part of what has been reported so far, and something we see time and time again in our work, is that the lives of some people in our society are seen as somehow less valuable than others. If it is true that only 1% of unexpected deaths of people with learning disabilities and 0.3% of older people with mental health problems were investigated then that is completely unacceptable and there has to be accountability for failures of this magnitude.
Whether you are old and have mental health problems, or live with a learning disability, you have the same rights as every other human being. Any life that is cut short, expectedly or otherwise, must be properly investigated, so that we can learn from mistakes and improve the situation for others.
Another key issue which has been widely reported and is extremely significant is that in nearly two thirds of investigations that were carried out there was no family involvement. We need to see family and friendship networks at the heart of how we support people. The idea that a death can be effectively investigated without talking to the people most directly affected, is completely nonsensical.
Finally, it appears that services consistently fail to learn from the past. How many reports have now been written about poor health care and people with learning disabilities? Has nothing been learnt from the Confidential Inquiry? Among many other things it recommended that there should be systems in place to ensure that local learning disability mortality data is analysed and published.
These leaked findings indicate that the problem is cultural, starting at the top with leadership and structure which directs commissioning, provision, oversight and the actual care given. Until we can be honest and face up to how attitudes are directly affecting how decisions are made, we cannot start to truly learn from mistakes.
It is only thanks to the tireless work of the Justice for LB Campaign that this terrible situation has come to light. It should not take years of relentless campaigning by families to reveal the truth. We need to have the systems in place to record and understand what is happening and a full and frank public investigation when things go wrong.
In terms of what needs to happen next, we need to see four key things happen:
It is so easy to forget that the numbers that get reported are real people with lives, families, hopes and aspirations. We owe it to them and their loved ones to get to the bottom of this as soon as possible so we can improve the service for others in the future.
Sue Turner is the at the National Development Team for Inclusion (NDTi)
NDTi is an organisation that promotes equal and inclusive lives for people in their communities, particularly where ageing or disability are issues
Sue Turner's blog is a personal opinion and does not necessarily reflect the views of the NDTi.