NHS England commissioned a review of the Southern Health NHS Foundation Trust, which killed five people between 2011 and 2015.
Trust provides services for mental health and learning disabilities.
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A report on the second phase of the study was then published, highlighting how the “significant gap” in care occurred during the same period.
All the clerical mistakes, information not shared between caregivers, and medication mistakes were emphasized.
Ron Shields, Chief Executive Officer of the Southern Health NHS Foundation Trust, said: Thanks to the panel and everyone who has contributed.
“On behalf of trust, we once again apologize to families affected by the 2011-2015 tragedy highlighted in Pasco’s first report. While focusing on improving current and future services, the past Never forget or reduce your mistakes.
“As the report admits, trust has improved significantly since then, but what we need to do to work with service users and their families to solve the problem from the beginning each time. There are many more. “
The report concluded that changes have been made since death to improve relationships between caregivers, service users, and their families, but these changes were “not universal in impact.” “.
He added that the “gold standard” has not yet been achieved.
Shields added: “Making these changes is our absolute priority, and we will develop a detailed plan that reflects the recommendations of the report, where we have already made changes and how we will make the necessary further improvements. Indicates. “
The report recommends that the Southern Health NHS Foundation Trust strengthen its links with Hampshire Healthwatch to ensure that service users, families and caregivers are heard.
It is also recommended that information sharing between clinicians be improved, learning be more widely shared throughout the organization, and additional improvements in monitoring be made.
Jeff Hill, an activist who has helped his family after his loved one’s death, said:
“It fully justifies the decision of bereaved families and other potential witnesses to withdraw from the process in February.
In the report, Trust’s CEO expresses a generous apology for the mistakes, mistakes and pains caused by the incident involving the bereaved family.
“But to my knowledge and belief, he hasn’t contacted any of them directly.”
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Southern Health NHS Trust Report Discovers “Systematic” Failures Related to Care Death
Source link Southern Health NHS Trust Report Discovers “Systematic” Failures Related to Care Death