Improving learning from patient deaths

Failures in how Trusts investigate patient deaths have come under the spotlight in recent years and, following a high profile case, in 2013, the Secretary of State for Health asked the Care Quality Commission (CQC) to look into the issue. Eighteen year old Connor Sparrowhawk, who had a learning disability and epilepsy, died while receiving care at an assessment and treatment centre run by Southern Health NHS Trust. Initially the Trust classified Connor’s death as a result of ‘natural causes’, and his family had concerns about the way they planned to investigate Connor’s death. Following campaigns by Connor’s family, an independent investigation was commissioned by the Trust that found his death was entirely preventable, and the Coroner in 2015 concluded that there had been failures in his care and neglect had contributed to his death. 

In response to the concerns raised as a result of this case, NHS England commissioned a review of all mental health and learning disability deaths at Southern Health NHS Foundation Trust from April 2011 to March 2015. The report, published in December 2015, identified a number of failings in the way the Trust recorded and investigated deaths and highlighted that certain groups of patients including people with a learning disability and older people receiving mental healthcare were far less likely to have their deaths investigated by the Trust. In fact, fewer than 1% of deaths reported in learning disability services and 0.3% of all deaths in mental health services for older people had been investigated. 

Following the findings, the CQC was asked to look at how acute, community and mental health NHS Trusts across the country investigate and learn from deaths to find out whether opportunities for prevention of death have been missed, and identify any improvements that are needed. The findings of a national review concluded 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. The quality regulator has raised significant concerns about the quality of investigations 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.