The NHS is missing opportunities to learn from patient deaths and too many families are not being included or listened to when an investigation happens.
A CQC report raises significant concerns about the quality of investigation processes led by NHS trusts into patient deaths and the failure to prioritise learning from these deaths so that action can be taken to improve care for future patients and their families.
CQC’s review looked at how NHS trusts across the country identify, report, investigate and learn from the deaths of people using their services.
The review found that there is no consistent national framework in place to support the NHS to investigate deaths that may be the result of problems in care. This can mean that opportunities to help future patients are lost, and families are not properly involved in investigations – or are left without clear answers.
The CQC’s review was carried out at the request of the Secretary of State for Health following the findings of the NHS England commissioned report into the deaths of people with a learning disability or mental health problem who were being cared for by Southern Health NHS Foundation Trust.
The regulator is now calling on its national partners to work together to develop a national framework, so that NHS trusts have clarity on the actions required when someone in their care dies. This will ensure that learning is promoted and used to improve care, and so that families are consistently listened to as equal partners alongside NHS staff.
Professor Sir Mike Richards, Chief Inspector of Hospitals at the Care Quality Commission, said: “We found that too often, opportunities are being missed to learn from deaths so that action can be taken to stop the same mistakes happening again.
“Families and carers are not always properly involved in the investigations process or treated with the respect they deserve. We found this was particularly the case for the families and carers of people with a mental health problem or learning disability that we spoke to during the review, which meant that these deaths were not always identified, well investigated or learnt from.
“While elements of good practice exist, there is not a single NHS trust that is getting it completely right currently. An agreed framework needs to be established that sets out exactly what the NHS should do when someone dies and ensures that families and carers are fully involved and treated with respect.”
Of the 27 investigation reports reviewed by CQC across the 12 NHS trusts, only three could demonstrate that they had considered the families’ perspectives. Inspectors found that families and carers were not always informed or kept up to date about investigations – often causing them further distress.
Also, CQC found wide variation in the way NHS organisations become aware of the deaths of people in their care and inconsistencies in how decisions are made on whether to carry out a review or investigation after a patient has died. While healthcare staff seemed to understand the expectation to report patient safety incidents, there is no agreed process that recognises which deaths may require a specific response.
This lack of clarity and consistency means that there will be some deaths which have not been investigated which should have been.
Furthermore, NHS trusts do not always record whether that patient also had a mental health illness or learning disability. These groups of patients will often be receiving care from multiple organisations that would need to be aware of their death, in order to be in a position to consider whether the care they had provided may require a review to identify problems.
Another concern CQC identified was that specialised training and support is not universally provided to staff completing investigations and that many staff completing reviews and investigations do not have protected time to carry out investigations which can reduce consistency in approach, even within the same services.