• NHS England’s national clinical director for learning disability says problems identified at Southern Health not confined to one provider
  • Dominic Slowie says failure to properly investigate and learn from the deaths of people with learning disabilities reflect “societal attitude”
  • NHS England has launched the world’s first national review of deaths of people with learning disabilities

Failures by Southern Health Foundation Trust to investigate and learn from the deaths of people with learning disabilities are probably replicated in “lots of hospitals” across the country, an NHS England official has said.

Dominic Slowie, national clinical director for learning disability, said the issue reflected a “societal attitude to people with learning disability”.

In December the audit firm Mazars published a report highlighting failures at Southern Health to properly investigate and learn from the deaths of mental health and learning disability service users.

Speaking at an event last week, Dr Slowie said the NHS was “not where we should be… not good enough” when it came to reporting and learning from the deaths of people with a learning disability.

“The Mazars audit and the subsequent NHS Improvement and Care Quality Commission involvement in Southern Health suggest that we are not investigating the deaths of people with learning disability to the level we should be and learning the lessons,” he said.

However, he said that the problems identified by Mazars were probably not isolated to Southern Health.

“I don’t think this is just an index of that particular trust, even if they do have specific challenges,” he said.

“I think that… this reflects some of the societal attitude to people with learning disability, and I think if you went into lots of hospitals in the country you might find similar issues.”

While the NHS was not currently where it should be, Dr Slowie said the health service was leading the way in trying to improve understanding about the deaths of people with learning disabilities.

Last year NHS England launched the world’s first national initiative to review, and ultimately reduce, premature deaths of people with learning disabilities.

The learning disabilities mortality review programme is run by Bristol University, and in November began piloting reviews of deaths of people with learning disabilities aged 4-75 at the time of their death in the North East and Cumbria. Reviews will then be rolled out nationwide incorporating learning from the pilots.

“We’ve commissioned the first ever national learning disability and mortality review body in the world – it’s happening in England,” Dr Slowie said.

“That’s going well – we’ve got a number of trained individuals who are going to investigate deaths of people with learning disability.

“Our partners in the CQC and in NHS Improvement and indeed [NHS England medical director] Sir Bruce Keogh, are making sure that all hospitals whether they’re specialist hospitals or acute general hospitals, will be able to detail the story and the extent of people with learning disability dying, how old they are when they die, what they die from [and] whether we could have prevented any of those deaths.”

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