Mental health trusts to probe ‘red flag’ deaths to prevent repeat of Connor Sparrowhawk failings

Mental health trusts are being asked to review deaths for “red flags” to improve patient treatment and prevent failings being repeated in light of the death of a teenager with learning difficulties.

Inspections of deaths that occurred after one of four scenarios should prompt further investigation under guidance published on Tuesday for the NHS by the Royal College of Psychiatrists.

These are where concerns over care have been raised, where the patient has suffered psychosis or an eating disorder during their last spell of care, where a patient was recently admitted to a psychiatric ward, or where the patient was under the care of a crisis and home treatment team at the time of death.

Any of the four red flags should prompt a further voluntary investigation of the patient’s notes to determine a rating of their care, with advice on why it was good or poor.

Work on the guidance was prompted because of the death of Connor Sparrowhawk, an 18-year-old with epilepsy who drowned in a bath at an NHS care unit in Oxford in 2013.

Southern Health NHS Foundation Trust, which ran the unit, admitted various failings led to his death.

Dr Adrian James (pictured), the Royal College of Psychiatrists’ registrar, said: “It is crucial that ways of improving services are learned from patients’ deaths. Our guidance offers those services a great opportunity to do exactly that.”

Care minister Caroline Dinenage said: “Each preventable death is a tragedy and we must learn from every one.

“This new guidance will equip trusts with the tools to more quickly identify areas of improvement, provide more support for families and implement changes to better care for people with severe mental health conditions.”

_{Copyright (c) Press Association Ltd. 2018, All Rights Reserved. Picture (c) Royal College of Psychiatrists.}