The Challenging Behaviour Foundation responds to the publication of the Mazars report


This afternoon, the long-awaited Mazars report was finally published. The report examined all deaths of people receiving care from Mental Health and Learning Disability services at Southern Health NHS Trust between April 2011 and March 2015. The BBC reported last week on findings from a draft version of the report. These leaked findings suggested that the NHS has failed to investigate the unexpected deaths of more than 1,000 people since 2011.


Viv Cooper, Chief Executive at the Challenging Behaviour Foundation, said

“Eight years after Mencap published “Death by Indifference”, today’s report confirms that people with learning disabilities are dying prematurely and that these deaths are avoidable. There can be no excuses.”

“Our thoughts are with the families affected. It is vital that independent support and advice is put in place for families whose experiences are as described in the report or who are concerned about their loved one.

“The Mazars report reveals that 64% of investigations into unexpected deaths did not involve the family, and there was confusion in Southern Health about who should provide support to families. This is not acceptable.”

“As was revealed in last week’s leak, the Mazars report states that the likelihood of a person with a learning disability’s unexpected death being investigated was just 1%. Further to this, even when investigations into unexpected deaths were carried out they were of a poor quality.”

“The Challenging Behaviour Foundation suspects that the failures detailed in this report are not unique to Southern Health, and suggest wider issues throughout the system. We are calling for the Department of Health and NHS England to take urgent action to determine if this is so and take action accordingly.”

“We are also expecting those responsible for the failures detailed in this report to be properly held to account.”


Support for Families following the publication of the Mazars Report

If you are concerned about your relative’s current care you should contact your relative’s care manager to address immediate issues. Any safeguarding concerns should be raised with your local safeguarding team.  You can find out more about raising concerns at this link. If your relative is in an assessment and treatment unit you might find our range of resources produced in partnership with Mencap useful.

Cruse Bereavement Care are available to offer support. The CBF have a small Family Support Service able to offer telephone support and information to family carers of children and adults with a severe learning disability. The Family Support Service can be reached via email at or by calling 0300 666 0126.

For families looking for legal advice, Leigh Day have set up an online form for families to contact their health rights team. This can be accessed via their website here. We also have an information sheet of frequently asked legal questions which you might find useful. The Law Society also has a database of solicitors here.

Inquest is a small charity providing free advice to people providing free advice to people bereaved by a death in custody and detention (including detained patients).

You may also wish to contact, or read advice from, a mental health charity such as Mind or Rethink.


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