Learning, candour and accountability – a report by the Care Quality Commission

Posted on 13th December 2016

A year after a review commissioned by NHS England uncovered failings at Southern Health Foundation Trust (see previous blog 2/9/16), the Care Quality Commission (‘CQC’) has looked into how acute, community and mental health trusts across the country investigate and learn from deaths of people who have been in their care, and their report is out today.

The CQC were unable to identify any trust that demonstrated good practice across all aspects of identifying, reviewing and investigating deaths and ensuring that learning is implemented, but saw some trusts demonstrate promising practice at individual steps.

This lack of consistency is perhaps unsurprising given the relatively recent introduction of the NHS Serious Incident Framework (1 April 2015), but the recommendations have a familiar ring to them, as summarized in their press release:

  • “Learning from deaths needs much greater priority within the NHS to avoid missing opportunities to improve care.
  • Bereaved relatives and carers must receive an honest and caring response from health and social care providers and the NHS should support their right to be meaningfully involved.
  • Healthcare providers should have a consistent approach to identifying and reporting the deaths of people using their services and share this information with other services involved in a patient’s care.
  • There needs to be a clear approach to support healthcare professionals’ decisions to review and/or investigate a death, informed by timely access to information.
  • Reviews and investigations need to be high quality and focus on system analysis rather than individual errors. Staff should have specialist training and protected time to undertake investigations.
  • Greater clarity is needed to support agencies working together to investigate deaths and to identify improvements needed across services and commissioning.
  • Learning from reviews and investigations needs to be better disseminated across trusts and other health and social care agencies, ensuring that appropriate actions are implemented and reviewed.
  • More work is needed to ensure the deaths of people with a mental health or learning disability diagnosis receive the attention they need.”

Health Secretary Jeremy Hunt is expected to respond to the report in the Commons today, when he is likely to announce a requirement for trusts to collect and record information on unexpected deaths so lessons can be learned.

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