Inconsistent lessons from patient deaths

  • Date: 15 December 2016

NHS INVESTIGATIONS into patient deaths in England are failing to prioritise learning opportunities and are not properly involving families looking for answers, according to a review by the Care Quality Commission.

The review was carried out at the request of the Secretary of State for Health following the findings of a report into the deaths of people with learning disabilities or mental health problems being cared for by Southern Health NHS Foundation Trust.

The CQC looked at how NHS trusts across England identify, report, investigate and learn from the deaths of people using their services. The review found no consistent national framework in place to support the NHS in investigating deaths that may be the result of problems in care. This can mean that opportunities to help future patients are lost, and families are not properly involved in investigations, or are left without clear answers.

Evidence was gathered during visits to a sample of 12 NHS trusts, a national survey of all NHS trusts providing acute, mental health and community services and interviews and discussions with over 100 families and carers, as well as information from charities and NHS professionals.

The involvement of family and carers in investigations into patient deaths varied considerably, with only three out of the 27 investigation reports reviewed by the CQC demonstrating that they had considered these perspectives. Inspectors found that families and carers were not always informed or kept up to date about investigations – often causing them further distress. Many also reported that they were not treated with kindness, respect or sensitivity during the investigation process.

The CQC found wide variation in the way NHS organisations become aware of the deaths of people in their care and inconsistencies in how decisions are made on whether to carry out a review or investigation after a patient has died. Healthcare staff seemed to understand the expectation to report patient safety incidents but there was no agreed process that recognises which deaths may require a specific response. This lack of clarity and consistency means that some important investigations were missed out.

Some NHS trusts also do not always record whether patients under treatment had a mental health illness or learning disability. Such patients often receive care from multiple organisations which would need to be aware of any death in order to determine whether a review was required.

Another concern identified by the CQC involved the specialised training and support needed for staff completing investigations and a lack of protected time to carry out investigations, which can lead to inconsistency even within the same services.

The regulator is calling on its national partners to work together to develop a national framework, so that NHS trusts have clarity on the actions required when someone in their care dies. This will ensure that learning is promoted and used to improve care, and that families are consistently listened to as equal partners alongside NHS staff.

Professor Sir Mike Richards, Chief Inspector of Hospitals at the Care Quality Commission, said: "We found that too often, opportunities are being missed to learn from deaths so that action can be taken to stop the same mistakes happening again.

"While elements of good practice exist, there is not a single NHS trust that is getting it completely right currently. An agreed framework needs to be established that sets out exactly what the NHS should do when someone dies and ensures that families and carers are fully involved and treated with respect.

"This is a system-wide problem, which needs to become a national priority. CQC will support the drive for change by sharing best practice, identifying concerns and taking action to protect patients when necessary. The changes we plan to make to our future inspections will place greater emphasis on how NHS trusts learn following the deaths of their patients, as part of our assessments of how ‘well-led’ they are, holding boards to account if improvements are needed."

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