An investigation by the Care Quality Commission has found widespread failure to properly investigate and learn from patient deaths, resulting in lost opportunities to improve care.
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.
The review also found that there is no consistent national framework in place to support the NHS to investigate deaths. This can mean that opportunities to help future patients are lost, and grieving families are not properly involved in investigations – or are left without clear answers.
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 families and carers of people with a mental health problem or learning disability 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 are fully involved and treated with respect. Investigations into patient deaths 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.”
He added: “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 investigate 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 providers and interviews and discussions with over 100 families, 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 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 while 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.”
CQC has made a number of recommendations to support a change in approach from all parts of the system. In particular, the Department of Health and the National Quality Board, working with Royal Colleges and families, should develop a new single framework on learning from death. This should define good practice in relation to identifying, reporting, investigating and learning from deaths in care and provide guidance for when an independent investigation may be appropriate. This should complement the Serious Incident Framework and clearly define roles and responsibilities.
The CQC also called on NHS Digital and NHS Improvement to assess how they can facilitate the development of reliable and timely systems, so that information about a death is available to all providers who have recently been involved in that patient’s care. They should also provide guidance on a standard set of information to be collected by providers on all patients who have diedHealth Education England should work with the Healthcare Safety InvestigationBranch (HSIB) and providers to develop approaches to ensuring that staff have the capability and capacity to carry out good investigations of deaths and write good reports, with a focus on these leading to improvements in care.
Provider organisations and commissioners must also work together to review and improve their local approach following the death of people receiving care from their services. Provider Boards should ensure that national guidance is implemented at a local level, so that deaths are identified, screened and investigated, when appropriate and that learning from deaths is shared and acted on. In addition, emphasis must be given to engaging families and carers.
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.”
A full copy of the ‘Learning, candour and accountability: A review of the way NHS Trusts review and investigate the deaths of patients in England’ review is available on CQC’s website: www.cqc.org.uk
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