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13.04.16

CQC to carry out inspections of how trusts learn from deaths

The CQC will implement recommendations following the scandal at Southern Health by investigating how all acute, community and mental health trusts learn from the deaths of patients.

The CQC announced it will write to all the trusts asking how many patients in contact with their services have died, how they decide which of these should be investigated and how they carry out the investigations.

The regulator will also seek to find out how trusts involve families and how they learn from the results, with a particular focus on the deaths of patients with learning disabilities and mental health problems. They will then conduct phone interviews with 30 trusts and visit 12.

The announcement follows a recommendation from health secretary Jeremy Hunt as part of the government’s response to the scandal at Southern Health trust, which the CQC found recently is still failing to address safety concerns despite the Mazars report criticising the trust for investigating just 13% of 1,454 deaths of patients with learning disabilities and mental health problems.

Professor Sir Mike Richards, CQC’s chief inspector of hospitals, said: “Very many people are under the care of secondary healthcare services at the time of their death.

“For most, the care provided has prolonged their life, eased their suffering and helped them to die with dignity. However, this is not the case for everybody. Every year thousands of people under the care of NHS trusts die prematurely because their treatment or care has not been as good as it could have been. Healthcare workers might have failed to identify an illness that could have been treated, not provided the advice that might have prevented an illness developing, not made a life-saving intervention with a person who is critically ill or made some other error that contributed to a premature death.

“It is essential that, when this happens, NHS services identify and investigate the circumstances of these deaths so that staff can learn from them and reduce the likelihood of a similar event happening in the future. It is also essential, that NHS providers are open and honest with the families and carers of people who die whilst under their care.”

He added that the CQC’s review aims to find out to what extent NHS trusts are learning organisations when it comes to investigating the deaths of people under their care and how well they support and engage with the families of people who have died.

(Image c. Peter Facey)

From 1 April, CQC inspection fees have increased by as much as 75% for trusts with an income of £125m-£225m. And under new safety measures announced recently by Hunt, an independent medical examiner will review all deaths from April 2018.

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