Public Health

19.03.19

Trusts still ‘failing to embrace open learning culture’ and must improve pace of change, says CQC

Trusts are not doing enough to review and learn from the deaths of their patients and “failure to fully embrace an open, learning culture” is holding organisations back, according to the CQC.

Published today, the health inspectorate’s report looks into how well trusts learn from deaths and support and engage with families when patients die.

The report found that whilst inspections have shown good processes at some NHS trusts, many trusts have struggled to make the changes needed in dealing with patient deaths.

It also highlighted a particular area of concern around engaging with bereaved families.

The CQC said issues such as fear of engaging with the families, a lack of staff of training and concerns about repercussions on professional careers highlight problems with the culture of some trusts which may be a barrier to putting guidance into practice.

Miriam Deakin, director of policy and strategy at NHS Providers, said: “When a person dies under NHS care it is vital to ensure that opportunities to learn and improve care are not missed.

“It is encouraging to see that trusts’ awareness of new national guidance on learning from deaths is high, and that some – though not all – have made good progress.”

Two years after national guidance for trusts to initiate a standardised approach to learning from deaths, inspectors did find that awareness of the guidance was high and some trusts had taken action to revise policies.

But the CQC was concerned with the large variety in the amount of progress trusts have made, and the report found some evidence that community organisations were struggling because of poor integration and because guidance was too “acute-focused.”

Professor Ted Baker, CQC’s chief inspector of hospitals, said: “The speed of progress varies, and our review indicates that problems with the culture of some organisations is preventing sufficient progress.

“Cultural change is not easy and will take time, but we cannot lose momentum and the current pace of change is not fast enough.

“I urge NHS trusts to use the examples of good practice highlighted in this report to help identify the key drivers to improve learning from deaths, to build on the progress they have made so far and to accelerate the changes needed.”

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Image credit: PA

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