Southern Health criticised for putting 'patients at risk'
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".
Southern Health provides services in Hampshire, Dorset, Wiltshire, Oxfordshire and Buckinghamshire.
Following Mr Petter's departure, one of the trust's 13 public governors Mark Aspinall, also resigned.
In his statement, the public governor for Oxfordshire and Buckinghamshire said he had been disappointed by the "apparent lack of drive and determination" by some governors in dealing with troubles faced by the trust.
The CQC - the independent regulator for health and social care in England - launched an inspection of Southern Health in January after it was found hundreds of deaths at the trust between April 2011 and March 2015 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.
Analysis: David Fenton, Health Correspondent, BBC South
It looks like civil war has broken out at top of Southern Health.
One governor resigned saying his colleagues were "apathetic or intransigent" about making changes - in effect they didn't seem to care very much.
Another has said he thinks the chief executive should now go.
What's interesting is why this has happened now - because these criticisms in the CQC report, they're nothing new. They have been around for months.
What is new is the finger of blame is pointed squarely at the leadership, and the suggestion they let down staff and their patients.
One remark by Mark Aspinall, the governor who resigned today, sums that up. He said his wife asked him if he was still proud to be part of Southern Health and he thought about it, and said no.
The report revealed there were 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 said it would impose management changes at the trust if progress was not made.
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".
"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 2012 review leaked earlier this week found staff did not feel Slade House, an in-patient unit for people with learning difficulties in Oxford where Connor Sparrowhawk died, was safe and it was dirty and difficult to track the care of patients.
An inquest jury found in October that neglect contributed to Connor's death.
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.
Connor's stepfather, Richard Huggins, said: "If we'd known anything of the things we now know, we wouldn't have admitted Connor to that unit.
"We have found out in the three years since it happened so many things that are deeply disturbing, not just about Connor but about many other people. What I find particularly disturbing about this case is, if Connor hadn't died, none of this would have come out."
In his resignation letter Mr Aspinall said: "I feel hamstrung by the constant barrage of critical news that keeps hitting the trust. Unable to move forward but not seemingly able to correct the mistakes either."
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."
Liberal Democrat MP and former health minister Norman Lamb called for further resignations.
He said: "I think the whole board has to be held to account but also, I think the chief executive has to go."