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 have said.
Southern Health 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.
Trust chairman Mike Petter resigned on Thursday ahead of the publication of the Care Quality Commission’s report.
He said he was stepping down “to allow new board leadership to take forward the improvements”.
The CQC’s inspection in January was ordered after an investigation looked at all deaths at the trust between April 2011 and March 2015 and found hundreds had not been investigated properly.
Now the watchdog has said 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 and ligature points across its sites.
The report revealed there had been 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.
Health service regulator NHS Improvement has said it would impose management changes at the trust if progress was not made to address the CQC’s concerns.
Dr Paul Lelliott, deputy chief inspector of hospitals, said that, despite staff efforts, risks to patients were “not driving the senior leadership or board agenda”.
He said: “It is clear that the trust had still missed opportunities to learn from adverse incidents and to take action to reduce the chance of similar events happening in the future.
“I am concerned that the leadership of this trust shows little evidence of being proactive in identifying risk to the people it cares or of 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 leaked 2012 review found staff did not feel Slade House, an in-patient unit for people with learning difficulties in Oxford, was safe and that it was dirty and difficult to track the care of patients at the unit.
An inquest jury found in October that neglect contributed to Connor’s death at the unit.
Dr Sara Ryan, his mother, described seeing the 2012 report as “shocking and harrowing” and said she would be asking police to open an investigation.
She said: “It is a national scandal. It shows that certain people in our society aren’t given the same healthcare treatment as other people.
“How much more failing do we have to have evidence for before the chief executive and the rest of the board are removed.”
Trust Chief Executive Katrina Percy said the CQC’s findings sent “a clear message to the leadership… that more improvements must be delivered and as rapidly as possible”.
She added: “We will continue to share regular updates on progress publicly to demonstrate improvement and help re-build trust in our services.”
Southern Health provides services in Hampshire, Dorset, Wiltshire, Oxfordshire and Buckinghamshire.
Analysis: David Fenton, BBC South health correspondent
This will make grim reading for anyone at the top of Southern Health, not to mention the trust’s thousands of patients and their carers.
It’s a repeat of the same criticisms we’ve been hearing for months – but with the added barb that it’s the leadership who are to blame.
Time and again the CQC make the point that patients could still be at risk and that senior staff and leaders at the trust just don’t seem to be getting a grip on the situation.
This must have been on the mind of the chairman Mike Petter when he announced his sudden and unexpected resignation last night.
The families of patients who died in the care of Southern Health have long called for changes at the top, and that is just what has happened.
But the issue of keeping safe those patients who are often deeply disturbed and who might want to harm themselves or others is much more problematic.
This trust has more than 220 buildings, 250,000 patients and operates across a swathe of southern England, and many are now wondering whether it’s just too big to cope with the tasks ahead.