Investigations into the deaths of patients with a learning disability

The request was partially successful.

Dear NHS Merton Clinical Commissioning Group,

Please would you provide the following information for your CCG:

1) the number of deaths of patients with a learning disability that occurred in the last three years (by years defined as 1/4/16 - 31/3/17, 1/4/17 - 31/3/18, 1/4/18 to present).

2) the number of independent investigations into the deaths of patients with a learning disability that you have commissioned in the last three years (defined as above)

3a) the number of deaths of patients with a learning disability that have resulted in an inquest in the last three years (defined as above)

3b) of those inquests the number that were an Article 2 inquest

I look forward to hearing from you,
Many thanks
Dr George Julian

Foi (NHS NEL CSU), NHS Merton Clinical Commissioning Group

Dear Dr Julian

 

RE: Freedom of Information Request

 

I am writing to formally acknowledge your request for information
regarding investigations into patient deaths which will be processed under
the Freedom of Information Act 2000. I can confirm your request was
received on 19 March 2019 (as 18 March is counted as a non-working day due
to St Patrick’s Day) by NEL on behalf of the Clinical Commissioning Groups
(CCGs) listed below. The references for your requests are shown alongside.

 

NHS Merton CCG                            FOI.18.MERT261

 

An initial investigation is currently taking place into whether the
information you have requested is held by the CCGs and if so, whether it
can be released in accordance with the legislation.

 

Any fees applicable to this request will be detailed in writing as soon as
they can be determined. Your request will then be placed on hold and you
will have the choice of whether to proceed with your request. Should any
clarification of your request be required we will advise you accordingly.

 

If you require any assistance, or would like to discuss your request,
please do not hesitate to contact us quoting the reference number above.

 

Yours sincerely,

 

Freedom of Information Team
NEL
[1][NHS Merton CCG request email] 

 

Lower Marsh, 3^rd Floor
Waterloo, London, SE1 7NT

  

[2]www.nelcsu.nhs.uk 

[3]@NELCSU 

[4]LinkedIn 

 

 

 

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Foi (NHS NEL CSU), NHS Merton Clinical Commissioning Group

1 Attachment

Dear Dr Julian

 

RE:                  FOI.18.MERT261

 

Please see the attached response to your recent Freedom of Information
request on the behalf of NHS Merton Clinical Commissioning Group.

 

Kind regards,

Freedom of Information Team
NEL
[1][NHS Merton CCG request email]

 

1 Lower Marsh, 3^rd Floor 
Lower Marsh, London SE1 7NT

  

[2]www.nelcsu.nhs.uk 

[3]@NELCSU 

[4]LinkedIn

 

 

 

From: Foi (NHS NEL CSU)
Sent: 19 March 2019 10:04
To: 'George Julian' <[FOI #562841 email]>
Subject: Request acknowledged

 

Dear Dr Julian

 

RE: Freedom of Information Request

 

I am writing to formally acknowledge your request for information
regarding investigations into patient deaths which will be processed under
the Freedom of Information Act 2000. I can confirm your request was
received on 19 March 2019 (as 18 March is counted as a non-working day due
to St Patrick’s Day) by NEL on behalf of the Clinical Commissioning Groups
(CCGs) listed below. The references for your requests are shown alongside.

 

NHS Merton CCG                            FOI.18.MERT261

 

An initial investigation is currently taking place into whether the
information you have requested is held by the CCGs and if so, whether it
can be released in accordance with the legislation.

 

Any fees applicable to this request will be detailed in writing as soon as
they can be determined. Your request will then be placed on hold and you
will have the choice of whether to proceed with your request. Should any
clarification of your request be required we will advise you accordingly.

 

If you require any assistance, or would like to discuss your request,
please do not hesitate to contact us quoting the reference number above.

 

Yours sincerely,

 

Freedom of Information Team
NEL
[5][NHS Merton CCG request email] 

 

Lower Marsh, 3^rd Floor
Waterloo, London, SE1 7NT

  

[6]www.nelcsu.nhs.uk 

[7]@NELCSU 

[8]LinkedIn 

 

 

 

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Dear Foi (NHS NEL CSU),

Thanks for your response to my FOI request, can I just check whether you meant to answer 17 to Question 2, the number of independent investigations commissioned. Or are you referring to LEDER reviews, which you state in answer to Question 1 are not investigations?

Many thanks
George

Foi (NHS NEL CSU), NHS Merton Clinical Commissioning Group

Dear Dr Julian

 

The answer to question one is 34. They are notifications of deaths
received by LEDER. Therefore, not necessarily investigations.

The answer to question two is 17. It is the number of independent
investigations commissioned.

 

Kind regards

 

Freedom of Information Team
NEL
[1][NHS Merton CCG request email]

020 3049 5689

 

1 Lower Marsh, 3^rd Floor 
Lower Marsh, London SE1 7NT

  

[2]www.nelcsu.nhs.uk

[3]@NELCSU

[4]LinkedIn

 

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Dear Foi (NHS NEL CSU),

Sorry to come back on this again but I'm still not sure what your answer means.

I understand that you are saying there were 34 deaths, and you know this because they were notified to LEDER. In answer to the same question you state that LEDER reviews ARE NOT INVESTIGATIONS - which I agree with, they are partial, they only look at the time up to death, they are not independent etc etc etc

In answer to question two you say there have been 17 independent investigations. Can I just check once more that you have commissioned 17 independent investigations (as defined in the Serious Incident Framework as Level 3 investigations). Or do you mean that 17 of the 34 deaths notified to LEDER have been looked at and a review complete.

In which case the answer to the number of independent investigations is zero.

Does that make sense? LEDER reviews are not independent investigations. So I'm just trying to understand what the figure of 17 relates to.

Many thanks for your time,
Best wishes
George

Foi (NHS NEL CSU), NHS Merton Clinical Commissioning Group

Dear Dr Julian

 

Thank you very much for your further query on this request.

We do apologise for the typing error made during our original response and
any inconvenience caused.

 

I have now updated the response to reflect the correct figures. Please
note the figure 34 provided was a combination of both CCGs (NHS Merton &
NHS Wandsworth), which we identified as a typing error.

 

Updated response

 

1.       The number of deaths of patients with a learning disability that
occurred in the last three years (by years defined as 1/4/16 - 31/3/17,
1/4/17 - 31/3/18, 1/4/18 to present).

Since the LeDeR, Learning Disabilities Mortality Review, commenced from
May 2017 to the end of February 2019, the CCG has had 17 notifications of
deaths from Bristol University, the lead on LeDeR. The LeDeR is the
Learning Disabilities Mortality Review. The programme is commissioned by
NHS England to support local areas in England to review the deaths of
people with a learning disability to identify common themes and learning
points and provide support to local areas in their development of action
plans to take forward the lessons learned. The LeDeR Programme is not an
investigation nor is it aimed at holding any individual or organisation to
account”

 

2.       The number of independent investigations into the deaths of
patients with a learning disability that you have commissioned in the last
three years (defined as above)

17

 

3.        

a.       The number of deaths of patients with a learning disability that
have resulted in an inquest in the last three years (defined as above)
The CCG does not hold this information. You may want to contact coroner’s
office about your request. Their contact details are below.

[1]https://www.coronersociety.org.uk/chief-...

 

b.      Of those inquests the number that were an Article 2 inquest
The CCG does not hold this information. You may want to contact coroner’s
office about your request. Their contact details are below.

[2]https://www.coronersociety.org.uk/chief-...

Please note that your original request does not refer to Serious Incident
Framework as Level 3 investigations. As per the NHS Improvement website
below, they may be able to help with further statistics if need be. Please
contact them direct
([3]https://improvement.nhs.uk/resources/ser...).

 

Please also correct the figures provided for NHS Wandsworth CCG in our
response.
Please feel welcome to contact us if you need any further clarification.

 

Kind regards,

 

Freedom of Information Team
NEL
[4][NHS Merton CCG request email]

020 3049 5689

 

1 Lower Marsh, 3^rd Floor 
Lower Marsh, London SE1 7NT

  

[5]www.nelcsu.nhs.uk 

[6]@NELCSU 

[7]LinkedIn

 

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George Julian left an annotation ()

This is a bizarre response. The CCG state that LEDER reviews are not investigations (and for what its worth I agree with them, they're not), then they go on to respond that they have commissioned 17 investigations (through LEDER - which they previously say are not investigations).

So from what I can tell they've not commissioned 17 independent investigations.