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CQC flags systemic problem as not a single NHS trust learning from patient deaths

No NHS trust can demonstrate an acceptable approach to learning from the deaths of patients with learning disabilities and mental health problems, a major CQC review of the problem has found.

The report’s authors found they could not identify a single NHS trust that could demonstrate good practice across all aspects of identifying, reviewing, investigating and learning from deaths.

Instead, it found that there is no consistent system for how organisations identify that a patient in their care has died. Most patients are treated by multiple organisations and there is no system for one to notify the others. Electronic systems do not allow easy communication between organisations.

Staff use the Serious Incident Framework to decide whether to review and investigate deaths, which means that investigations will only happen if the patient’s care leads to a serious incident.

Employees are also not universally provided with specialist training in how to carry out investigations, while organisations work in isolation and reviews are significantly delayed.

Professor Sir Mike Richards, chief inspector of hospitals at the CQC, said: “Investigations into patient deaths must improve for the benefit of families and importantly, people receiving care in the future.

“This is a system-wide problem, which needs to become a national priority.”

The 2013 death of 18-year-old Connor Sparrowhawk, a patient at Southern Health, led to an investigation which found that the trust had failed to investigate more than a thousand unexpected patient deaths. Following a campaign by Sparrowhawk’s family, the trust admitted that his death had been preventable and was caused by “multiple systemic and individual failures”, and agreed to pay the family £80,000.

The CQC also carried out interviews and listening events with the families of deceased patients, many of whom complained about being shut out of the investigation into their loved one’s death.

Families and carers were regularly not informed of their rights when a loved one died and not kept up to date with investigations. Many argued that their involvement in the investigation was “tokenistic” and their views were not listened to compared to those of NHS staff.

National approach needed

Deborah Coles, director of INQUEST and member of the expert advisory group to the CQC review, said: “This report must be a wakeup call and result in concrete action. It ratifies what INQUEST and families have been saying for years.

“There is a defensive wall surrounding NHS investigations, an unwillingness to allow meaningful family involvement in the process and a refusal to accept accountability for NHS failings in the care of its most vulnerable patients.

“Political will and leadership is now required to drive change to a system which is not fit for purpose. We reiterate that only an independent investigation framework can tackle head-on the dangerous systems and practises which are costing peoples' lives. A clear programme of action for 2017 must follow this report, to which families must be integral.”

The CQC backed calls for a new national approach to learning from patient deaths. In particular, it said this should set out ways of involving families in investigations and reducing the increased risk of premature death for people with learning disabilities and mental illness.

In addition, it called for NHS Digital and NHS Improvement to review how they could develop better systems for sharing news of patient deaths, while Health Education England should work with the newly-formed Healthcare Safety Investigation Branch to ensure that staff have the capacity to carry out investigations.

A new approach to mortality

Separately, the Royal College of Physicians (RCP) is already leading a programme to develop a standard approach to learning from patient deaths.

Dr Kevin Stewart, clinical director of the RCP’s clinical effectiveness and evaluation unit, explained: “Having already been met with great enthusiasm by clinicians and healthcare leaders, it is pleasing to see this appetite and desire to improve reflected at this high level.

“We look forward to working with the CQC and partners to further develop this work, and imbedding a new consistent approach to mortality across all trusts. As healthcare professionals, we have a duty to provide a high quality of care to patients in the last stages of life, ensuring that all deaths are good deaths.”

Professor Dame Sue Bailey, chair of the Academy of Medical Royal Colleges, said the review “revealed what many in healthcare had suspected for a long time”.

“Put simply, we have consistently failed and continue to fail too many of the families of those who die whilst in our care,” she added. “This is not about blaming individuals, but about the health service learning the lessons from this report.”

Dame Julie Mellor, the Parliamentary and Health Service Ombudsman, also argued that the report was “a golden opportunity” to create “an open, honest working environment where NHS staff do not fear reprisals”.

Mike Durkin, national director of patient safety at NHS Improvement, said: “The NHS works tirelessly to deliver safe, high quality, care to patients across the country. However today’s report makes it clear that the whole system must do better when learning from care provided to people who die. 

“NHS Improvement’s next step will be to work closely with the Care Quality Commission, Department of Health, and our partners, to examine these findings and develop a clear approach to how we will support the NHS to identify, report, investigate and learn from patient deaths."

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