The Northamptonshire Healthcare Foundation is looking into care given to three people, after they passed away unexpected at a Northamptonshire mental health care facility. The three deaths occurred in July, August and September 2018 and only came to light when a featured in the trust’s learning from deaths report which was published some months later in November. Serious incidents have to be reported directly to the Care Quality Commission (CQC) with immediate action to be taken to establish the circumstances surrounding any death, according to NHS rules.

The trust currently provides community and mental health care services across the county and has released a statement on the alarming investigation;

During Quarter 2 2018/19 we instigated three serious incident investigations relating to unexpected deaths in our services, none of these deaths were in an inpatient setting. In line with the NHS England Serious Incident Framework we launched internal investigations into these deaths. The purpose of these investigations is to understand the circumstances of the unexpected deaths and identify any learning as part of the continuous improvement of our services. Our culture of continuous learning was recognised in our CQC rating of Outstanding in August 2018.”


There will be a 60 working day deadline surrounding the investigation with a team of staff looking into the circumstances of each of the three deaths. When contacted, the trust declined to make comment on whether the investigations have concluded;

We cannot confirm any further details as it may enable the patient to be identified, which goes against national guidance. Our priority is the safeguarding of patients, families and carers and this includes complete confidentiality.”

According to the NHS Serious Incident Framework: “Investigations carried out under this framework are conducted for the purposes of learning to prevent recurrence. They are not inquiries into how a person died (where applicable) as this is a matter for coroners. Neither are they conducted to hold any individual or organisation to account as other processes exist for that purpose including: criminal or civil proceedings, disciplinary procedures, employment law and systems of service and professional regulation, such as the Care Quality Commission and the Nursing and Midwifery Council, the Health and Care Professions Council, and the General Medical Council.”

Are they playing Russian roulette with people’s lives? The investigation aims to get to the bottom of what actually happened and the results will be available to view once the report is concluded.