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Trust continues to put patients at risk.

 The NHS mental health trust which ran a care unit where a teenager drowned in a bath is continuing to put patients at risk, inspectors claim.

Southern Health, which provides services in Hampshire, Dorset, Wiltshire, Oxfordshire and Buckinghamshire, failed to adopt safe bathing guidelines for two-and-a-half years after Connor Sparrowhawk died following an epileptic seizure in 2013. His unsupervised death led to a report into hundreds of unexplained deaths between April 2011 and March 2015.

Trust chairman, Mike Petter, resigned before publication of the report by independent care regulator, the Care Quality Commission's (CQC), saying he wanted to allow the new leadership of the board to progress improvements.

After Mr Petter's departure, one of the trust's 13 public governors, Mark Aspinall, also resigned saying he had been disappointed by the "apparent lack of drive and determination" by some governors to deal with the trust’s troubles.

The CQC report says that the trust has still not done enough to reduce "environmental risks" and condemned a low roof at a Winchester site that patients could climb onto.

The report revealed there were eight occasions where patients had climbed onto the roof between 2010 and 2015, as well as two in February - one of which involved a patient leaving the ward and then leaving the country.

CQC deputy chief inspector of hospitals Dr Paul Lelliott, said: "I am concerned that the leadership of this trust shows little evidence of being proactive in identifying risk to the people it cares for or taking action to address that risk."

He added that a new process to monitor serious incidents and deaths had been introduced by the trust in December, but it was too early to gauge its impact.

A 2012 review found staff did not feel Slade House, an in-patient unit for people with learning difficulties in Oxford where Connor Sparrowhawk died, was safe and it was dirty and difficult to track patients’ care.

An inquest jury found in October that neglect contributed to Connor's death.

His mother, Dr Sara Ryan, described seeing the 2012 report as "shocking and harrowing" and said she would be asking police to open an investigation.

Trust chief executive Katrina Percy said the CQC's findings sent "a clear message to the leadership that more improvements must be delivered as rapidly as possible. We will continue to share regular updates on progress publicly to demonstrate improvement and help re-build trust in our services."


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