A year after a review commissioned by NHS England uncovered failings at Southern Health Foundation Trust in the way the trust recorded and investigated deaths, the Care Quality Commission (CQC) has published its report on how NHS trusts across the country investigate and learn from deaths of people who have been in their care.
The report analyses whether opportunities for prevention of deaths have been missed and identifies improvements that are needed. It follows the findings of last year’s review which highlighted that certain groups of patients, including people receiving mental health care, were far less likely to have their deaths investigated by Southern Health NHS Foundation Trust. This meant 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.
The report published by the CQC finds that families and carers often have a poor experience of investigations and are not always treated with kindness, respect and honesty. Disturbingly, this is particularly the case for families and carers of people with a mental health problem or learning disability.
The CQC was not able to single out any trust that could demonstrate good practice across all aspects of the investigation process which includes: identifying, reviewing and investigating deaths and ensuring that learning is implemented. These findings could partially be attributed to the fact that terms like “preventable”, “avoidable” and “unexpected” mean different things to different trusts which may prevent an investigation from being undertaken, even though in many cases it is only possible to determine whether a death was preventable after an investigation has taken place. There is also no framework for NHS trusts setting out what trusts need to do learn from deaths resulting from problems in care. With regard to this, a recommendation is made to the Department of Health and the National Quality Board to develop a new single framework on learning from death.
Other recommendations include making learning from deaths a national priority, development of reliable and timely systems that ensure that information about a death is available to all providers who have recently been involved in that patient’s care, and ensuring that national guidance is implemented on a local level, so that deaths are identified, screened and investigated when appropriate.
Health Secretary Jeremy Hunt said rules would be published next year setting out how cases should be identified and looked into.
This report by the CQC is another significant contribution to the greater debate about the quality of care afforded to NHS patients and the importance of listening to patients and families.
Earlier this year an audit by The Royal College of Physicians of over 9,000 dying patients found that in 16% of cases where a “Do Not Resuscitate” (DNR) order was in place the decision was not discussed with relatives (almost 1 in 5 families). The decision to use DNR is ultimately a doctor's, but guidelines state medical staff have a duty to discuss this with relatives wherever possible. Hospitals must “do better”, and it was “unforgivable” not to tell families, report author Prof Sam Ahmedzai said.
The above reports indicate that there are clear variations in the support and services received across hospitals in relation to the death of patients. If you have concerns about the death of a loved one under NHS care, or the standard of the NHS's investigation please contact Lynne Foster on 01865 781010 or firstname.lastname@example.org. Lynne regularly represents clients at Inquests in the Coroner’s Court and has many years of experience in representing bereaved families in fatal claims.
Our review of the way NHS trusts review and investigate deaths has found that opportunities to learn from patient deaths are being missed – and too many families are not being included or listened to when an investigation takes place.