HEALTHCARE DELIVERY
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.”
Key recommendations
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 died. Health Education England should work with the Healthcare Safety Investigation
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.
FEBRUARY 2017
Branch (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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Photographee.eu - Fotolia/Adobe Stock.
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