Care Quality Commission
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CQC calls for action to end missed opportunities to learn from patient deaths

A national review by the Care Quality Commission (CQC) has found that the NHS is missing opportunities to learn from patient deaths and that too many families are not being included or listened to when an investigation happens.

In a report out today (Tuesday 13 December), the quality regulator has raised 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. CQC was asked to review how NHS trusts across the country investigate and learn from deaths to find out whether similar opportunities to learn from problems in care, which result in patient deaths were being missed elsewhere. While the review looked at trusts providing acute, community and mental health services, it placed a particular focus on people with mental health conditions and learning disabilities.

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.

“Investigations into problems in care prior to a patient's death must improve for the benefit of families and importantly, people receiving care in the future. We have made a number of recommendations for action as a result of this review.

“This is a system-wide problem, which needs to become a national priority. CQC will support the drive for change by sharing best practice, identifying concerns and taking action to protect patients when necessary. The changes we plan to make to our future inspections will place greater emphasis on how NHS trusts learn following the deaths of their patients, as part of our assessments of how ‘well-led’ they are, holding boards to account if improvements are needed.”

The review was based on evidence gathered during visits to a sample of 12 NHS trusts, a national survey of all NHS trusts providing acute, mental health and community services and interviews and discussions with over 100 families and carers, as well as information from charities and NHS professionals.

The review highlighted that the extent to which families and carers are involved in investigations of their relatives’ death varies considerably. 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. Many families and carers reported that they were not treated with kindness, respect or sensitivity during the investigation process, despite many NHS trusts stating that they value family involvement and have policies and procedures in place to support it.

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.

The review also 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. 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.

Professor Dame Sue Bailey, Chair of the Academy of Medical Royal Colleges said, “This landmark review reveals in stark detail what many in healthcare have suspected for a long time. Put simply, we have consistently failed and continue to fail too many of the families of those who die whilst in our care. This is not about blaming individuals, but about the health service learning the lessons from this report. Importantly this is not simply an issue for mental health organisations. We must now ensure we rapidly put in place system-wide changes so that NHS trusts always treat families as equal partners in a consistent manner with humanity, honesty and common decency when deaths occur. As the report recommends the Academy of Medical Royal Colleges will work with the National Quality Board and partners to take forward the recommendations and develop a new single framework on learning from deaths.’

Deborah Coles, Director of INQUEST and member of the Expert Advisory Group to the CQC Review, said: “This report must be a wakeup call and result in concrete action. It ratifies what INQUEST and families have been saying for years. 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.

“Political will and leadership is now required to drive change to a system which is not fit for purpose. We reiterate that only an independent investigation framework can tackle head-on the dangerous systems and practises which are costing peoples' lives. A clear programme of action for 2017 must follow this report, to which families must be integral."

Alongside the national agreed framework to inform best practice, CQC has made a number of recommendations to support a change in approach from all parts of the system. These have been presented to the Secretary of State for Health for consideration.

Our review of how NHS trusts investigate and learn from deaths

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Notes to editors

About the review:

To gather the evidence for the review, CQC:

  • Undertook a national survey of all NHS providers, and visited a sample of 12 NHS trusts (four acute, four community healthcare and four mental health NHS trusts).

    1. Homerton University Hospital NHS Foundation Trust
    2. Norfolk and Norwich University Hospitals NHS Foundation Trust
    3. Royal Devon and Exeter NHS Foundation Trust
    4. Sheffield Teaching Hospitals NHS Foundation Trust
    5. Gloucestershire Care Services NHS Trust
    6. Hounslow and Richmond Community Healthcare NHS Trust
    7. Leeds Community Healthcare NHS Trust
    8. Staffordshire and Stoke on Trent Partnership NHS Trust
    9. Cumbria Partnership NHS Foundation Trust
    10. Dorset Healthcare University NHS Foundation Trust
    11. North Essex Partnership NHS Foundation Trust
    12. West London Mental Health NHS Trust
  • Involved over 100 families through the public online community (including twitter chats), and held 1:1 interviews and listening events.
  • Gathered evidence from charities and NHS professionals.

In order to understand what problems exist and what improvements are required, CQC looked at five different aspects of the processes and systems NHS trusts need to have in place in order to learn from the death of a patient.

  • Involvement of families and carers: How are families and carers treated? Are they meaningfully involved and how do organisations learn from their experiences?
  • Identification and reporting: How are the deaths of people who use services identified and reported, including to other organisations involved in a patient's care, by NHS clinicians and staff, particularly when people die but are not an inpatient at the time of death?
  • Decision to review or investigate: Are there clear responsibilities and expectations to support the decision to review or investigate?
  • Reviews and investigations: Is there evidence that investigations are undertaken properly and in a way that is likely to identify missed opportunities for prevention of death and improving services?
  • Governance and learning: Do NHS trust boards have effective governance arrangements to drive quality and learning from the deaths of patients in receipt of care?

The review was supported by a number of external stakeholders and organisations.

About the Care Quality Commission

The Care Quality Commission (CQC) is the independent regulator of health and social care in England.

We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve.

We monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and we publish what we find to help people choose care.

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