The NHS is missing opportunities to learn from patient deaths and is failing to listen to bereaved families during investigations, a damning report by the Care Quality Commission has concluded.
The regulator says it has “significant concerns” about the quality of investigation processes led by NHS trusts into patient deaths and the failure to prioritise learning from cases so that action can be taken to improve care for future patients and their families.
Its review looked at how NHS trusts across the country identify, report, investigate and learn from the deaths of people using their services, and found “no consistent national framework” to support investigation of deaths that could be the result of problems in care.
The CQC is now calling on its national partners to work together to develop a national framework, so that NHS trusts have a clear to set actions to follow 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,” the regulator said.
Professor Sir Mike Richards, chief inspector of Hospitals at the CQC, 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,” said Professor Sir Mike Richards, chief inspector of hospitals at the Care Quality Commission, commenting on the findings.
“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 show that they had considered the families’ point of view. Inspectors found that families and carers were not always informed or kept up to date about investigations, often causing those bereaved further distress.
Also of concern, the review found that when caring and responding to patients’ physical health concerns, acute and community NHS trusts do not always record whether that patient also had a mental health illness or learning disability, and that specialised training and support is not universally provided to staff completing investigations.
“We have consistently failed and continue to fail too many of the families of those who die whilst in our care,” said Professor Dame Sue Bailey, chair of the Academy of Medical Royal Colleges, in response to the review’s findings. But she also stressed: “This is not about blaming individuals, but about the health service learning the lessons from this report”.
“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,” added Deborah Coles, director of INQUEST and member of the Expert Advisory Group to the CQC Review.
“Political will and leadership is now required to drive change to a system which is not fit for purpose…A clear programme of action for 2017 must follow this report, to which families must be integral.”
Jeremy Hunt ordered the CQC’s review last year on the back of the findings of an 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.
