- 06 June 2019
- 4 min read
Independent probe to examine patient deaths at NHS trust
The new investigation at Liverpool Community Health NHS Trust will be led by Dr Bill Kirkup, who published a report into the trust last year.
The Government has launched a new independent investigation into patient deaths and serious incidents at Liverpool Community Health NHS Trust.
The probe follows two previous reports which found evidence of patient harm and a culture of bullying at the “dysfunctional” trust.
Around 150 deaths are to be investigated as part of the new review, which will also look at wider patient harm.
Previous reports have found that patients suffered too many falls, with some left with hip fractures, had bed sores that were left to get worse and suffered from inadequate levels of care.
There were also huge staffing issues at the trust, with some staff who raised concerns being undermined or suspended for indefinite periods but not told the reason why.
Senior managers were so determined to achieve financial trust status that they turned a blind eye to issues, discouraged the reporting of incidents and were so inexperienced they did not realise they were out of their depth, the reports found.
The new investigation will be led by Dr Bill Kirkup, who published a report into the trust last year, and will look at serious incidents between 2010 and 2014.
It is expected to report by the end of 2020.
The trust has since been taken over by Mersey Care, which uncovered evidence of further failings.
Its chief executive David Rafferty said there was a “disturbing picture” of the way Liverpool Community Health had recorded incidents.
He said: “We don’t know what has been investigated properly or not investigated properly and therefore what lessons have been learned or not learned, that’s a position you don’t want to find yourself in in a health organisation.”
Mr Rafferty added: “We’ve looked at 150 deaths where – we’re not making a statement on whether people have had harm associated with death because many of the patients in our services are very ill anyway – but what we are very clearly saying is that the standard of investigation around the mortality review was not of a standard that would satisfy me or quite a lot of other independent clinicians that we’ve asked. So we feel those need to be reviewed properly.”
He said families of patients who may have been affected had not yet been informed but he expected them to be once the independent investigation was set up.
Mersey Care medical director David Fearnley said the system was “absolutely” not safe and in some cases deaths were not recorded as harm occurring to patients, so no further reviews took place.
“It’s likely that avoidable harm occurred because the learning that could have been in place wasn’t in place,” he said.
"We owe it to the patients and families affected by substandard care in Liverpool Community Health to establish the full extent of events and give them the answers they need" - Minister Stephen Hammond
The first and second stages of the new investigation will include looking at patient deaths at the trust.
It will also look at individual serious patient safety incidents that were not reported or adequately investigated by Liverpool Community Health.
The third stage will assess the level of patient harm and any lessons that can be learned, including on the role of senior managers.
Health minister Stephen Hammond said: “We owe it to the patients and families affected by substandard care in Liverpool Community Health to establish the full extent of events and give them the answers they need.
“The new investigation we have commissioned will review fresh evidence to make sure no stone is left unturned.
“We are prepared to take any action that is necessary – locally or nationally – to prevent such occurrences in the future.”
Dr Kirkup’s 2018 report identified “widespread failings” at the trust, which slashed costs in its pursuit of foundation trust status.
It was formed in 2010 and ran services for about 750,000 people on Merseyside until 2018.