Response to the Mazars Report

Today the Mazars report came out.

The report is an investigation into the deaths of people with learning disabilities who were under the care of Southern Health Trust.

You can read the Easy Read version of the report here.

This is Gary Bourlet’s response to the report.



Reading about the deaths of people under the care of Southern Health Trust made me feel very sad.

Somehow you go past being angry to being more sad.

Our condolences go out to all the families who have been affected by this.

There should be a memorial for people who’ve died in these places.


What the report says


The report found only 1 per cent of deaths in learning disability services were investigated.

I think this is wrong.

It’s important for organisations like Southern Health to be better because they’re supposed to be looking after people.

It’s also important that when organisations like Southern Health do things wrong, people should feel able to speak out about them.



The report criticised leadership in investigating the deaths of people with learning disabilities.

I think the leaders of Southern Health Trust like Katrina Percy should be sacked.

Their job is to keep people alive and well and they failed to do that. They then failed to properly investigate their deaths.

There needs to be good training for leaders because leaders should have a good understanding of people with learning disabilities.

This training could be carried out by people with learning disabilities and their families.

Commissioners also need to meet service users and their families to get a better understanding.

They should also have training so that they can improve services.

I think service users and families should be taking a leadership role.



The report says that Southern Health should be sharing information on deaths.

This is a good idea because then people would understand what’s happening.

The report says that information could be shared ‘for research and review’.  This could really help improve services.



The report said that families weren’t as involved in investigations of deaths as they should have been.

We need to make sure that families have answers and that they know exactly what happened.

We need to make sure families’ voices are heard.

Families are important.

The reason this report was written is because Connor Sparrowhawk died whilst he was in the care of Southern Health Trust.

Connor was also called LB which stands for Laughing Boy.



LB’s family has been working very hard to make sure that this report happens.

They’ve also been working on the LB Bill.

They didn’t want this to happen to anyone else.

However painful it was, they wanted to make sure that this never happened again.

This should have never happened in the first place. They should never have had to campaign.




The report makes recommendations about what Southern Health Trust should do now.

I think these recommendations are mostly good.

There are a few things that should be added.

People have done wrong and they need to be held to account.

Also to create real change we should be getting people back into the community with the support they need.

Hospitals like the ones run by Southern Health Trusts are institutions under a different name.

Those are things that we don’t want.

The report also talks about how there isn’t enough advocacy for service users.

This is because of all the cuts.

There needs to be more funding put into advocacy so that advocates can help make better improvements.



We’re still very far away from making sure these things don’t happen.

This report is just the beginning, we need more action.

Self-advocacy groups, service users and families need to come together to make change happen.

It’s also important to get more people’s attention to what’s been happening.

I would encourage people to tweet and to talk about it online using the hashtag #Mazars.

We know how sensitive and painful these issues are but something needs to be done and we need to be talking about it.

Doing nothing is not the answer.


More information


You can read the statement from the National Forum for People with Learning Disabilities and the National Valuing Families Forum here.

Lots of people are talking about the report on twitter. You can read what they are saying here.