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NHS trusts investigate just 15% of hospital deaths

Just a few days after the “appalling” findings in NHS England’s report on the avoidable deaths at Southern Health NHS FT, it has been revealed that just one in seven hospital fatalities are investigated.

In an investigation using Freedom of Information requests, the Guardian found that hospitals in England have only examined 209 out of 1,436 deaths of inpatients with learning disabilities since 2011.

The paper said that even concerning deaths classed as unexpected, hospitals only looked into one-third of incidents, despite concerns that these patients are at higher risk of dying while in care.

Professor Sir Mike Richards, the CQC’s chief inspector of hospitals for England, said these findings were “very concerning”, signalling that the organisation is keen to work with the Guardian to look at the information in greater detail.

“This will help us plan the review that CQC is already committed to doing,” he added.

The CQC is already working alongside the government and NHS England to undertake a focused inspection at Southern Health next year after a report on the provider’s string of preventable deaths of patients in mental health or learning disability services. It will focus primarily on how the trust investigates deaths, but will also launch a wider review into the investigation of deaths in a sample of all types of NHS trusts – including acute, mental health and community providers countrywide.

A spokesperson for the Department of Health reiterated the government’s view that trusts should look into all unexpected deaths, adding: “As the government’s response to Southern Health made clear, it is important that the NHS properly investigates unexpected deaths to learn lessons and improve care.

“That’s why the secretary of state has announced an investigation by the CQC into how deaths are investigated in all types of trusts. Prof Sir Bruce Keogh [NHS England medical director] also wrote to all NHS hospitals last week asking them for an assessment of their avoidable mortality to drive learning in the system.”

The paper’s analysis of data also showed wide variation in the way in which hospitals reviewed deaths, with some trusts – such as Somerset Partnership NHS FT, Northamptonshire Healthcare NHS FT and Rotherham, Doncaster and South Humber NHS Trust – looking into none of the unexpected deaths they had in their care in the last four years.

Figures obtained from Southern Health also indicated a discrepancy between what was investigated last week and what they were saying now. Audit firm Mazars found 93 unexpected deaths between 2011 and this year, but the trust said there had been only 67.

Learning disability charity Mencap urged the trust to explain this variation and said the investigation’s figures will leave “many families questioning whether their loved one’s death in NHS care should have been properly investigated, and show the need for the government to commission an independent investigation across the NHS on these failings”.

Earlier this month, the Parliamentary and Health Service Ombudsman also identified serious failings in the majority of hospital-led investigations, later urging the NHS to introduce a training programme for staff carrying out probes into complaints about avoidable harm and death.