Missed opportunities to learn from patient deaths in the NHS

By John Tingle

The National Health Service (NHS) in England’s quality regulator, the Care Quality Commission (CQC) has recently published a highly critical report on the way patient deaths are investigated in the NHS. The investigation follows events at the Southern Health NHS Foundation Trust where a number of failings were identified in the way patient deaths were identified and investigated. Certain groups of patients including people with a learning disability and older people receiving mental health care were far less likely to have their deaths investigated by this Trust. The Secretary of State for Health called for a CQC investigation into how acute, community and mental health NHS facilities across the country investigate and learn from deaths. The findings of the report are not good and major improvements in this area are needed across the NHS.

There are failings in openness, transparency and missed opportunities to learn important patient safety lessons. Families of patients and carers told the CQC reviewers that they often have a poor experience of investigations and are not always treated with kindness, respect, honesty and sensitivity. The CQC states that across their review they were unable to identify any NHS healthcare facility that could demonstrate good practice across all aspects of identifying, reviewing and investigating deaths and ensuring that learning from the events is implemented.

The review found inconsistency in the way organisations became aware of deaths. There is confusion and inconsistency in the methods and definitions used across the NHS to identify and report deaths leading to decisions being taken differently across NHS organisations.

“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”

Specialised training and support is not universally provided to staff completing investigations and many do not have protected time to do this. They have to fit the investigation in and around their other duties.

These were just some findings and a call is made by the CQC for it’s national partners to work together to develop a new single framework on learning from death which defines good practice, identifies and defines roles and responsibilities. A recommendation is also made to define what families and carers can expect from health carers when they are involved in the investigation process following the death of a family member or somebody that they provided care for. Approaches should be developed to ensure that staff have the capability and capacity   to carry out good investigations, write good reports and that these lead to care improvements being made.

What is most concerning is that it is only now, at the end of 2016, that the NHS has found out that major national problems exist within its health care facilities about investigating deaths. Why has action not been taken before now?

What is also particularly concerning is how the families and carers of patients feel about the way they have been treated. They require more involvement in the investigation process and not to be treated in a tokenistic manner but with due respect. Fundamentally we also need to learn and implement patient safety lessons arising from the investigations of deaths. This CQC report is yet another instance which shows how difficult it is proving for the NHS to develop a patient safety centered learning culture.

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