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“Learning disabled people don’t count in life or death” - INQUEST and family response to Mazars investigation

9 December 2015

Information leaked from the long awaited Mazars investigation into the deaths of mental health and learning disability patients, deliver a damning review of the investigation procedures carried out by Southern Health NHS Foundation Trust. The review was commissioned by NHS England following the death of 18 year old Connor Sparrowhawk. Connor, who had learning disabilities and autism, drowned in the bath while a patient at a Southern Health unit. 

The investigation looked at all deaths at the trust between April 2011 and March 2015 and identified a total of 10,306 deaths. Of this number, only 1% of those deaths involving individuals with learning disabilities were investigated. For over-65s with mental health problems it was just 0.3%.

Some of the key findings of the investigation included the following:

  • The trust could not demonstrate a comprehensive systematic approach to learning from deaths
  • Despite the trust having comprehensive data on deaths, it failed to use it effectively
  • Too few deaths among those with learning disability and over-65s with mental health problems were investigated, and some cases should have been investigated further
  • In nearly two-thirds of investigations, there was no family involvement

INQUEST Director, Deborah Coles said: 

“This report should send shockwaves across the NHS. The failure to investigate deaths of some of society’s most vulnerable people is a scandal that must be urgently addressed. These findings reiterate the need for independent and robust investigations into the deaths of mental health and learning disability patients. 

What is so disturbing is that this report only came about because of the tireless fight for the truth by the family of Connor Sparrowhawk. This damning report must now prompt a national inquiry. Their families deserve nothing less.”

Sara Ryan, Connor Sparrowhawk's mother, said:

"This report only confirms that learning disabled people don't count in life or death. This should not be acceptable in a so called advanced society"

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