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15.12.17

NHS to be first in world to publish avoidable death data

The NHS is to become the world’s first health organisation to publish data on avoidable deaths, the Department of Health has confirmed.

The announcement comes following the 2016 Care Quality Commission report that found that the NHS was missing opportunities to learn from patient deaths, and that families were not being included in investigations.

Each trust will publish its own data quarterly, and over three quarters of trusts in England will have released their first estimates by the end of December.

The data will not be collated centrally, and each trust will be required to make its own assessment of the number of deaths due to problems in care, which the DH says will allow trusts to focus on learning from mistakes and sharing lessons locally.

It is hoped that by collecting the data and taking action in response to failings in care, trusts will be able to give an open and honest account of the circumstances leading to a death.

Health secretary Jeremy Hunt called each death from a failing in care “an absolute tragedy.”

The NHS has been ranked as the world’s safest healthcare system for a second time, but Hunt said that despite this it still has “a long way to go.”

“Too often I have heard from families saying that after mistakes happen they feel like a wall has gone up in the NHS, but publishing this data will help give grieving families the openness and answers they deserve,” he added. 

“It marks a significant milestone in ensuring the NHS learns from every tragic case, sharing lessons across the whole system to prevent mistakes recurring and ultimately delivering safer care for all patients in the future.”

The DH estimates that there are somewhere between 1,250 and 9,000 avoidable deaths each year, ranging from high-profile failings in care, to terminally ill patients who die earlier than expected.

Chief inspector of hospitals at the Care Quality Commission, Professor Ted Baker, said that this level of transparency will be “central to ensuring the safety” of NHS services.

“We will use this information alongside the findings of our inspections to identify where providers must make improvements and to share good practice where we find hospitals that are doing it well,” he explained.

NHS Improvement’s executive medical director, Dr Kathy McLean, explained that trusts are in the process of a “culture change” in terms of learning from deaths.

“Trusts across the country are improving how they engage and support bereaved families, how they ensure they learn from mistakes and share good practice.

“We have been clear that the change required of trust boards is one of culture and leadership, rather than one of process and counting,” she said.

Chris Hopson, chief executive of NHS Providers, welcomed the news, calling it “encouraging” that many trusts are publishing data about deaths where problems with care may have been a factor.

“Trusts are already finding that this approach can help to improve the way they engage with families and carers more openly and collaboratively.

“When this happens the experience, safety and quality of care is much better,” he explained.

However, Hopson warned: “It is important that the information is used constructively, in the spirit of learning and shared good practice, and not to construct league tables that would inevitably mislead and potentially alarm the public.”

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Comments

Kath   16/12/2017 at 23:37

This is great news but with a big BUT. It is still dependent on hospitals identifying the avoidable death. The patients' relatives still have no voice . The key issue is HOW and BY WHOM a death is deemed to have been avoidable.

Simon Elsdon   18/12/2017 at 18:19

This is a parody of the patient safety developed by Don Berwick and currently practiced so well by the Scottish Patient Safety programme. We must use the Berwick method, unbelievably taught in NHS but apparently ignored, to systematically develop the processes needed to reduce hospital mortality and not this ad hoc travesty.

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