HEALTHCARE DELIVERY
Improving learning from patient deaths
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
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